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Beck J, Fung C, Strbian D, Bütikofer L, Z'Graggen WJ, Lang MF, Beyeler S, Gralla J, Ringel F, Schaller K, Plesnila N, Arnold M, Hacke W, Jüni P, Mendelow AD, Stapf C, Al-Shahi Salman R, Bressan J, Lerch S, Hakim A, Martinez-Majander N, Piippo-Karjalainen A, Vajkoczy P, Wolf S, Schubert GA, Höllig A, Veldeman M, Roelz R, Gruber A, Rauch P, Mielke D, Rohde V, Kerz T, Uhl E, Thanasi E, Huttner HB, Kallmünzer B, Jaap Kappelle L, Deinsberger W, Roth C, Lemmens R, Leppert J, Sanmillan JL, Coutinho JM, Hackenberg KAM, Reimann G, Mazighi M, Bassetti CLA, Mattle HP, Raabe A, Fischer U. Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial. Lancet 2024; 403:2395-2404. [PMID: 38761811 DOI: 10.1016/s0140-6736(24)00702-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/16/2024] [Accepted: 04/04/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to assess whether decompressive craniectomy plus best medical treatment in these patients improves outcome at 6 months compared to best medical treatment alone. METHODS In this multicentre, randomised, open-label, assessor-blinded trial conducted in 42 stroke centres in Austria, Belgium, Finland, France, Germany, the Netherlands, Spain, Sweden, and Switzerland, adults (18-75 years) with a severe intracerebral haemorrhage involving the basal ganglia or thalamus were randomly assigned to receive either decompressive craniectomy plus best medical treatment or best medical treatment alone. The primary outcome was a score of 5-6 on the modified Rankin Scale (mRS) at 180 days, analysed in the intention-to-treat population. This trial is registered with ClincalTrials.gov, NCT02258919, and is completed. FINDINGS SWITCH had to be stopped early due to lack of funding. Between Oct 6, 2014, and April 4, 2023, 201 individuals were randomly assigned and 197 gave delayed informed consent (96 decompressive craniectomy plus best medical treatment, 101 best medical treatment). 63 (32%) were women and 134 (68%) men, the median age was 61 years (IQR 51-68), and the median haematoma volume 57 mL (IQR 44-74). 42 (44%) of 95 participants assigned to decompressive craniectomy plus best medical treatment and 55 (58%) assigned to best medical treatment alone had an mRS of 5-6 at 180 days (adjusted risk ratio [aRR] 0·77, 95% CI 0·59 to 1·01, adjusted risk difference [aRD] -13%, 95% CI -26 to 0, p=0·057). In the per-protocol analysis, 36 (47%) of 77 participants in the decompressive craniectomy plus best medical treatment group and 44 (60%) of 73 in the best medical treatment alone group had an mRS of 5-6 (aRR 0·76, 95% CI 0·58 to 1·00, aRD -15%, 95% CI -28 to 0). Severe adverse events occurred in 42 (41%) of 103 participants receiving decompressive craniectomy plus best medical treatment and 41 (44%) of 94 receiving best medical treatment. INTERPRETATION SWITCH provides weak evidence that decompressive craniectomy plus best medical treatment might be superior to best medical treatment alone in people with severe deep intracerebral haemorrhage. The results do not apply to intracerebral haemorrhage in other locations, and survival is associated with severe disability in both groups. FUNDING Swiss National Science Foundation, Swiss Heart Foundation, Inselspital Stiftung, and Boehringer Ingelheim.
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Affiliation(s)
- Jürgen Beck
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Christian Fung
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lukas Bütikofer
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery, University of Bern, Bern, Switzerland; Department of Neurology, University of Bern, Bern, Switzerland
| | - Matthias F Lang
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Seraina Beyeler
- Department of Neurology, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Karl Schaller
- Department of Neurosurgery, University of Geneva, Geneva, Switzerland
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research, LMU University Hospital, Munich, Germany
| | - Marcel Arnold
- Department of Neurosurgery, University of Bern, Bern, Switzerland
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Christian Stapf
- Department of Neurosciences, Université de Montréal, and Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences and Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jenny Bressan
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Stefanie Lerch
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Arsany Hakim
- University Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Bern, Switzerland
| | | | - Anna Piippo-Karjalainen
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany; Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen, University Hospital Aachen, Aachen, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Philip Rauch
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Dorothee Mielke
- Department of Neurosurgery, University Hospital Goettingen, Goettingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Hospital Goettingen, Goettingen, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Enea Thanasi
- Department of Neurosurgery, Justus-Liebig-Universität Gießen, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, Justus-Liebig-Universität Gießen, Gießen, Germany; Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - L Jaap Kappelle
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Robin Lemmens
- University Hospitals Leuven, Department of Neurology, Leuven, Belgium
| | - Jan Leppert
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jose L Sanmillan
- Department of Neurosurgery, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Katharina A M Hackenberg
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gernot Reimann
- Klinikum Dortmund, Klinikum der Universität Witten-Herdecke, Dortmund, Germany
| | - Mikael Mazighi
- Department of Neurology, Lariboisière University Hospital and Department of Interventional Neuroradiology, Rothschild Foundation Hospital, FHU Neurovasc, INSERM 1144, Paris Cité Université, Paris, France; Department of Neurointensive Care, Rothschild Foundation Hospital, Paris France
| | | | | | - Andreas Raabe
- Department of Neurosurgery, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University of Bern, Bern, Switzerland; Department of Neurology, Basel University Hospital, University of Basel, Basel, Switzerland.
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Alquisiras-Burgos I, Hernández-Cruz A, Peralta-Arrieta I, Aguilera P. Resveratrol Prevents Cell Swelling Through Inhibition of SUR1 Expression in Brain Micro Endothelial Cells Subjected to OGD/Recovery. Mol Neurobiol 2024; 61:2099-2119. [PMID: 37848729 DOI: 10.1007/s12035-023-03686-0] [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: 11/23/2022] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
The SUR1-TRPM4-AQP4 complex is overexpressed in the initial phase of edema induced after cerebral ischemia, allowing the massive internalization of Na+ and water within the brain micro endothelial cells (BMEC) of the blood-brain barrier. The expression of the Abcc8 gene encoding SUR1 depends on transcriptional factors that are responsive to oxidative stress. Because reactive oxygen species (ROS) are generated during cerebral ischemia, we hypothesized that antioxidant compounds might be able to regulate the expression of SUR1. Therefore, the effect of resveratrol (RSV) on SUR1 expression was evaluated in the BMEC cell line HBEC-5i subjected to oxygen and glucose deprivation (OGD) for 2 h followed by different recovery times. Different concentrations of RSV were administered. ROS production was detected with etidine, and protein levels were evaluated by Western blotting and immunofluorescence. Intracellular Na+ levels and cellular swelling were detected by imaging; cellular metabolic activity and rupture of the cell membrane were detected by MTT and LDH release, respectively; and EMSA assays measured the activity of transcriptional factors. OGD/recovery increased ROS production induced the AKT kinase activity and the activation of SP1 and NFκB. SUR1 protein expression and intracellular Na+ concentration in the HBEC-5i cells increased after a few hours of OGD. These effects correlated with cellular swelling and necrotic cell death, responses that the administration of RSV prevented. Our results indicate that the ROS/AKT/SP1-NFκB pathway is involved in SUR1 expression during OGD/recovery in BMEC of the blood-brain barrier. Thus, RSV prevented cellular edema formation through modulation of SUR1 expression.
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Affiliation(s)
- Iván Alquisiras-Burgos
- Laboratorio de Patología Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Insurgentes Sur #3877, CDMX, 14269, Mexico City, Mexico
- Departamento Neurociencia Cognitiva, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Ciudad Universitaria, CDMX, 04510, Mexico City, Mexico
| | - Arturo Hernández-Cruz
- Departamento Neurociencia Cognitiva, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Ciudad Universitaria, CDMX, 04510, Mexico City, Mexico
| | - Irlanda Peralta-Arrieta
- Laboratorio de Transducción de Señales, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan #4502, CDMX, 14080, Mexico City, Mexico
| | - Penélope Aguilera
- Laboratorio de Patología Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Insurgentes Sur #3877, CDMX, 14269, Mexico City, Mexico.
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Pelz JO, Kenda M, Alonso A, Etminan N, Wittstock M, Niesen WD, Lambeck J, Güresir E, Wach J, Lampmannn T, Dziewas R, Wiedmann M, Schneider H, Bayas A, Christ M, Mengel A, Poli S, Brämer D, Lindner D, Pfrepper C, Roth C, Salih F, Günther A, Michalski D. Outcomes After Decompressive Surgery for Severe Cerebral Venous Sinus Thrombosis Associated or Not Associated with Vaccine-Induced Immune Thrombosis with Thrombocytopenia: A Multicenter Cohort Study. Neurocrit Care 2024; 40:621-632. [PMID: 37498459 PMCID: PMC10959787 DOI: 10.1007/s12028-023-01782-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 06/09/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Clinical observations indicated that vaccine-induced immune thrombosis with thrombocytopenia (VITT)-associated cerebral venous sinus thrombosis (CVST) often has a space-occupying effect and thus necessitates decompressive surgery (DS). While comparing with non-VITT CVST, this study explored whether VITT-associated CVST exhibits a more fulminant clinical course, different perioperative and intensive care unit management, and worse long-term outcome. METHODS This multicenter, retrospective cohort study collected patient data from 12 tertiary centers to address priorly formulated hypotheses concerning the clinical course, the perioperative management with related complications, extracerebral complications, and the functional outcome (modified Rankin Scale) in patients with VITT-associated and non-VITT CVST, both with DS. RESULTS Both groups, each with 16 patients, were balanced regarding demographics, kind of clinical symptoms, and radiological findings at hospital admission. Severity of neurological symptoms, assessed with the National Institute of Health Stroke Scale, was similar between groups at admission and before surgery, whereas more patients with VITT-associated CVST showed a relevant midline shift (≥ 4 mm) before surgery (100% vs. 68.8%, p = 0.043). Patients with VITT-associated CVST tended to undergo DS early, i.e., ≤ 24 h after hospital admission (p = 0.077). Patients with VITT-associated CVST more frequently received platelet transfusion, tranexamic acid, and fibrinogen perioperatively. The postoperative management was comparable, and complications were evenly distributed. More patients with VITT-associated CVST achieved a favorable outcome (modified Rankin Scale ≤ 3) at 3 months (p = 0.043). CONCLUSIONS Although the prediction of individual courses remains challenging, DS should be considered early in VITT-associated CVST because an overall favorable outcome appears achievable in these patients.
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Affiliation(s)
- Johann Otto Pelz
- Department of Neurology, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Martin Kenda
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Campus, Virchow-Klinikum, Berlin, Germany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Wolf-Dirk Niesen
- Department of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Johannes Wach
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Tim Lampmannn
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Rainer Dziewas
- Department of Neurology and Neurorehabilitation, Klinikum Osnabrueck, Osnabrueck, Germany
| | - Markus Wiedmann
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
- Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Antonios Bayas
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Monika Christ
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Annerose Mengel
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | - Sven Poli
- Department of Neurology and Stroke, University Hospital Tuebingen, Eberhard-Karls University, Tuebingen, Germany
| | - Dirk Brämer
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Christian Pfrepper
- Division of Haemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Farid Salih
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Campus, Virchow-Klinikum, Berlin, Germany
| | - Albrecht Günther
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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Walter J, Alhalabi OT, Schönenberger S, Ringleb P, Vollherbst DF, Möhlenbruch M, Unterberg A, Neumann JO. Prior Thrombectomy Does Not Affect the Surgical Complication Rate of Decompressive Hemicraniectomy in Patients with Malignant Ischemic Stroke. Neurocrit Care 2024; 40:698-706. [PMID: 37639204 PMCID: PMC10959817 DOI: 10.1007/s12028-023-01820-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Even though mechanical recanalization techniques have dramatically improved acute stroke care since the pivotal trials of decompressive hemicraniectomy for malignant courses of ischemic stroke, decompressive hemicraniectomy remains a mainstay of malignant stroke treatment. However, it is still unclear whether prior thrombectomy, which in most cases is associated with application of antiplatelets and/or anticoagulants, affects the surgical complication rate of decompressive hemicraniectomy and whether conclusions derived from prior trials of decompressive hemicraniectomy are still valid in times of modern stroke care. METHODS A total of 103 consecutive patients who received a decompressive hemicraniectomy for malignant middle cerebral artery infarction were evaluated in this retrospective cohort study. Surgical and functional outcomes of patients who had received mechanical recanalization before surgery (thrombectomy group, n = 49) and of patients who had not received mechanical recanalization (medical group, n = 54) were compared. RESULTS The baseline characteristics of the two groups did significantly differ regarding preoperative systemic thrombolysis (63.3% in the thrombectomy group vs. 18.5% in the medical group, p < 0.001), the rate of hemorrhagic transformation (44.9% vs. 24.1%, p = 0.04) and the preoperative Glasgow Coma Score (median of 7 in the thrombectomy group vs. 12 in the medical group, p = 0.04) were similar to those of prior randomized controlled trials of decompressive hemicraniectomy. There was no significant difference in the rates of surgical complications (10.2% in the thrombectomy group vs. 11.1% in the medical group), revision surgery within the first 30 days after surgery (4.1% vs. 5.6%, respectively), and functional outcome (median modified Rankin Score of 4 at 5 and 14 months in both groups) between the two groups. CONCLUSIONS A prior mechanical recanalization with possibly associated systemic thrombolysis does not affect the early surgical complication rate and the functional outcome after decompressive hemicraniectomy for malignant ischemic stroke. Patient characteristics have not changed significantly since the introduction of mechanical recanalization; therefore, the results from former large randomized controlled trials are still valid in the modern era of stroke care.
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Affiliation(s)
- Johannes Walter
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - O T Alhalabi
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - S Schönenberger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - P Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - D F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - A Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - J-O Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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Sengupta SK, Aggarwal R, Singh MK. Correlation Between Volume and Pressure of Intracranial Space With Craniectomy Surface Area and Brain Herniation: A Phantom-Based Study. Neurotrauma Rep 2024; 5:293-303. [PMID: 38560491 PMCID: PMC10979661 DOI: 10.1089/neur.2024.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
There are proponents of decompressive craniectomy (DC) and its various modifications who claim reasonable clinical outcomes for each of them. Clinical outcome in cases of traumatic brain injury, managed conservatively or aided by different surgical techniques, depends on multiple factors, which vary widely among patients and have complex interplay, making it difficult to compare one case with another in absolute terms. This forms the basis of the perceived necessity to have a standard model to study, compare, and strategize in this field. We designed a phantom-based model and present the findings of the study aimed at establishing a correlation of the volume of intracranial space and changes in intracranial pressure (ICP) with surface area of the craniectomy defect created during DC and brain herniation volume. A roughly hemispherical radio-opaque container was scanned on a 128-slice computed tomography scanner. Craniectomies of different sizes and shapes were marked on the walls of the phantom. Two spherical sacs of stretchable materials were subsequently placed inside the phantom, fixed to three-way connectors, filled with water, and connected with transducers. The terminals of the transducer cables were coupled with the display monitor through a signal amplifier and processor module. Parts of the wall of the phantom were removed to let portions of the sac herniate through the defect, simulating a DC. Volume measurements using AW volume share 7® software were done. Resection of a 12.7 × 11.5 cm part of the wall resulted in a 10-cm-diameter defect in the wall. Volume differential of 35 mL created a midline shift of 5 mm to the side with lesser volume. When measuring pressure in two stretchable sacs contained inside the phantom, there always remained a pressure differential ranging from 1 to 2 mm Hg in different recordings, even with sacs on both sides containing an equal volume of fluids. Creating a circular wall defect of 10 cm in diameter with an intracavitary pressure of 35 mm Hg on the ipsilateral sac and 33 mm on the contralateral sac recorded with intact walls, resulted in a true volume expansion of 48.411 cm3. The herniation resulted in a reduction of pressure in both sacs, with the pressure recorded as 25 mm in the ipsilateral sac and 24 mm in the contralateral sac. The findings closely matched those of the other model-based studies. Refinement of the materials used is likely to provide a valid platform to study cranial volume, ICP, craniectomy size, and brain prolapse volume in real time. The model will help in pre-operatively choosing the most appropriate technique between a classical DC, a hinge craniotomy, and an expansive cranioplasty technique in cases of refractory raised ICP.
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Affiliation(s)
| | - Rohit Aggarwal
- Department of Radiology, Command Hospital Southern Command (Pune), India
| | - Manish Kumar Singh
- Department of Anaesthesia, Command Hospital Southern Command (Pune), India
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Fernandez LL, Griswold D, Khun I, Rodriguez De Francisco DV. Innovative Solutions for Patients Who Undergo Craniectomy: Protocol for a Scoping Review. JMIR Res Protoc 2024; 13:e50647. [PMID: 38451601 PMCID: PMC10958337 DOI: 10.2196/50647] [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: 12/15/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) is a widely used procedure to alleviate high intracranial pressure. Multidisciplinary teams have designed and implemented external medical prototypes to improve patient life quality and avoid complications following DC in patients awaiting cranioplasty (CP), including 3D printing and plaster prototypes when available. OBJECTIVE This scoping review aims to understand the extent and type of evidence about innovative external prototypes for patients who undergo DC while awaiting CP. METHODS This scoping review will use the Joanna Briggs Institute methodology for scoping reviews. This scoping review will include noninvasive medical devices for adult patients who undergo DC while waiting for CP. The search strategy will be implemented in MEDLINE, Embase, Web of Science, Scielo, Scopus, and the World Health Organization (WHO) Global Health Index Medicus. Patent documents were also allocated in Espacenet, Google Patents, and the World Intellectual Property Organization (WIPO) database. RESULTS This scoping review is not subject to ethical approval as there will be no involvement of patients. The dissemination plan includes publishing the review findings in a peer-reviewed journal and presenting results at conferences that engage the most pertinent stakeholders in innovation and neurosurgery. CONCLUSIONS This scoping review will serve as a baseline to provide evidence for multidisciplinary teams currently designing these noninvasive innovations to reduce the risk of associated complications after DC, hoping that more cost-effective models can be implemented, especially in low- and middle-income countries. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50647.
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Affiliation(s)
- Laura L Fernandez
- Clinical & Translational Science Institute and Center for Global Surgery, University of Utah, Salt Lake City, UT, United States
| | - Dylan Griswold
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Isla Khun
- University of Cambridge, Cambridge, United Kingdom
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Simard JM, Wilhelmy B, Tsymbalyuk N, Shim B, Stokum JA, Evans M, Gaur A, Tosun C, Keledjian K, Ciryam P, Serra R, Gerzanich V. Brain Swelling versus Infarct Size: A Problematizing Review. Brain Sci 2024; 14:229. [PMID: 38539619 PMCID: PMC10968884 DOI: 10.3390/brainsci14030229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 05/16/2024] Open
Abstract
In human stroke, brain swelling is an important predictor of neurological outcome and mortality, yet treatments to reduce or prevent brain swelling are extremely limited, due in part to an inadequate understanding of mechanisms. In preclinical studies on cerebroprotection in animal models of stroke, historically, the focus has been on reducing infarct size, and in most studies, a reduction in infarct size has been associated with a corresponding reduction in brain swelling. Unfortunately, such findings on brain swelling have little translational value for treating brain swelling in patients with stroke. This is because, in humans, brain swelling usually becomes evident, either symptomatically or radiologically, days after the infarct size has stabilized, requiring that the prevention or treatment of brain swelling target mechanism(s) that are independent of a reduction in infarct size. In this problematizing review, we highlight the often-neglected concept that brain edema and brain swelling are not simply secondary, correlative phenomena of stroke but distinct pathological entities with unique molecular and cellular mechanisms that are worthy of direct targeting. We outline the advances in approaches for the study of brain swelling that are independent of a reduction in infarct size. Although straightforward, the approaches reviewed in this study have important translational relevance for identifying novel treatment targets for post-ischemic brain swelling.
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Affiliation(s)
- J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Bradley Wilhelmy
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Natalya Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Bosung Shim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Madison Evans
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Anandita Gaur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Prajwal Ciryam
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Riccardo Serra
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.W.); (N.T.); (B.S.); (J.A.S.); (M.E.); (A.G.); (C.T.); (K.K.); (R.S.); (V.G.)
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8
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Angelini C, Zangrossi P, Mantovani G, Cavallo MA, De Bonis P, Scerrati A. The effect of antiplatelet and anticoagulant therapies on clinical outcome of patients undergoing decompressive craniectomy: a systematic review. Front Neurol 2024; 15:1336760. [PMID: 38385039 PMCID: PMC10879343 DOI: 10.3389/fneur.2024.1336760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Objective This systematic review aims to investigate a potential correlation between the administration of antiplatelets (APs) or anticoagulants (ACs) and perioperative complications, with a particular focus on hemorrhagic events, in patients undergoing decompressive craniectomy (DC). Additionally, the secondary objective is to assess the neurological outcomes in patients undergoing DC while taking APs/ACs, comparing them to patients not on APs/ACs. Methods The study utilized PubMed and Science Direct as primary online medical databases for the systematic review. Articles underwent screening based on title, abstract, and full-text review. Four studies meeting the inclusion criteria were selected for comprehensive analysis. Results Our findings suggest that the administration of APs/ACs in patients undergoing DC does not significantly impact functional outcomes. Notably, the occurrence of rebleeding within 6 months and other complications, including infections, appears to be less frequent in patients taking APs compared to those not taking APs/ACs. Conclusion Literature-derived data on the association between APs/ACs and DC presented considerable heterogeneity and insufficient volume for robust statistical analysis. Consequently, a definitive conclusion regarding the influence of suspending or continuing these therapies on complications and clinical outcomes cannot be confidently reached at present. To address this, a large-scale prospective study is warranted to gather substantial and precise data, facilitating a nuanced understanding of how to balance the risks and benefits associated with antiplatelet and anticoagulant agents in the context of decompressive craniectomy.
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Affiliation(s)
- Chiara Angelini
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Pietro Zangrossi
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Giorgio Mantovani
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Michele Alessandro Cavallo
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Pasquale De Bonis
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Minimally Invasive Neurosurgery Unit, Ferrara University Hospital, Ferrara, Italy
| | - Alba Scerrati
- Department of Neurosurgery, Sant’Anna University Hospital, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
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Pelz JO, Engelmann S, Scherlach C, Bungert-Kahl P, Dabbagh A, Lindner D, Michalski D. No Harmful Effect of Endovascular Treatment before Decompressive Surgery-Implications for Handling Patients with Space-Occupying Brain Infarction. J Clin Med 2024; 13:918. [PMID: 38337612 PMCID: PMC10856747 DOI: 10.3390/jcm13030918] [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: 12/04/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
This study explored short- and mid-term functional outcomes in patients undergoing decompressive hemicraniectomy (DHC) due to space-occupying cerebral infarction and asked whether there is a potentially harmful effect of a priorly performed endovascular treatment (EVT). Medical records were screened for patients requiring DHC due to space-occupying cerebral infarction between January 2016 and July 2021. Functional outcomes at hospital discharge and at 3 months were assessed by the modified Rankin Scale (mRS). Out of 65 patients with DHC, 39 underwent EVT before DHC. Both groups, i.e., EVT + DHC and DHC alone, had similar volumes (280 ± 90 mL vs. 269 ± 73 mL, t-test, p = 0.633) and proportions of edema and infarction (22.1 ± 6.5% vs. 22.1 ± 6.1%, t-test, p = 0.989) before the surgical intervention. Patients undergoing EVT + DHC tended to have a better functional outcome at hospital discharge compared to DHC alone (mRS 4.8 ± 0.8 vs. 5.2 ± 0.7, Mann-Whitney-U, p = 0.061), while the functional outcome after 3 months was similar (mRS 4.6 ± 1.1 vs. 4.8 ± 0.9, Mann-Whitney-U, p = 0.352). In patients initially presenting with a relevant infarct demarcation (Alberta Stroke Program Early CT Score ≤ 5), the outcome was similar at hospital discharge and after 3 months between patients with EVT + DHC and DHC alone. This study provided no evidence for a harmful effect of EVT before DHC in patients with space-occupying brain infarction.
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Affiliation(s)
- Johann Otto Pelz
- Department of Neurology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Simone Engelmann
- Institute of Neuroradiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Cordula Scherlach
- Institute of Neuroradiology, University Hospital Leipzig, 04103 Leipzig, Germany
| | | | - Alhuda Dabbagh
- Department of Neurology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, 04103 Leipzig, Germany
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10
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Lee SH, Ko MJ, Lee YS, Cho J, Park YS. Clinical impact of craniectomy on shunt-dependent hydrocephalus after intracerebral hemorrhage: A propensity score-matched analysis. Acta Neurochir (Wien) 2024; 166:34. [PMID: 38270816 DOI: 10.1007/s00701-024-05911-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/19/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE A consensus on decompressive craniectomy for intracerebral hemorrhage (ICH) has not yet been established. We aimed to investigate the development of shunt-dependent hydrocephalus based on the method of ICH surgery, with a focus on craniectomy. METHODS We retrospectively enrolled 458 patients with supratentorial ICH who underwent surgical hematoma evacuation between April 2005 and December 2021 at two independent stroke centers. Multivariate analyses were performed to characterize risk factors for postoperative shunt-dependent hydrocephalus. Propensity score matching (1:2) was undertaken to compensate for group-wise imbalances based on probable factors that were suspected to affect the development of hydrocephalus, and the clinical impact of craniectomy on shunt-dependent hydrocephalus was evaluated by the matched analysis. RESULTS Overall, 43 of the 458 participants (9.4%) underwent shunt procedures as part of the management of hydrocephalus after ICH. Multivariate analysis revealed that intraventricular hemorrhage (IVH) and craniectomy were associated with shunt-dependent hydrocephalus after surgery for ICH. After propensity score matching, there were no statistically significant intergroup differences in participant age, sex, hypertension status, diabetes mellitus status, lesion location, ICH volume, IVH occurrence, or IVH severity. The craniectomy group had a significantly higher incidence of shunt-dependent hydrocephalus than the non-craniectomy group (28.9% vs. 4.3%, p < 0.001; OR 9.1, 95% CI 3.7-22.7), craniotomy group (23.2% vs. 4.3%, p < 0.001; OR 6.6, 95% CI 2.5-17.1), and catheterization group (20.0% vs. 4.0%, p = 0.012; OR 6.0, 95% CI 1.7-21.3). CONCLUSION Decompressive craniectomy seems to increase shunt-dependent hydrocephalus among patients undergoing surgical ICH evacuation. The decision to perform a craniectomy for patients with ICH should be carefully individualized while considering the risk of hydrocephalus.
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Affiliation(s)
- Shin Heon Lee
- Department of Neurosurgery, Chung-Ang University Medical Center, Chung-Ang University College of Medicine, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea
| | - Myeong Jin Ko
- Department of Neurosurgery, Chung-Ang University Medical Center, Chung-Ang University College of Medicine, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea
| | - Young-Seok Lee
- Department of Neurosurgery, Chung-Ang University Medical Center, Chung-Ang University College of Medicine, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea
| | - Joon Cho
- Department of Neurosurgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Yong-Sook Park
- Department of Neurosurgery, Chung-Ang University Medical Center, Chung-Ang University College of Medicine, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Korea.
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11
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Nagy L, Morgan RD, Collins RA, Kharbat AF, Garza J, Belirgen M. Impact of timing of decompressive craniectomy on outcomes in pediatric traumatic brain injury. Surg Neurol Int 2023; 14:436. [PMID: 38213457 PMCID: PMC10783660 DOI: 10.25259/sni_472_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 11/16/2023] [Indexed: 01/13/2024] Open
Abstract
Background Decompressive craniectomy (DC) can be utilized in the management of severe traumatic brain injury (TBI). It remains unclear if timing of DC affects pediatric patient outcomes. Further, the literature is limited in the risk assessment and prevention of complications that can occur post DC. Methods This is a retrospective review over a 10-year period across two medical centers of patients ages 1 month-18 years who underwent DC for TBI. Patients were stratified as acute (<24 h) and subacute (>24 h) based on timing to DC. Primary outcomes were Glasgow outcome scale (GOS) at discharge and 6-month follow-up as well as complication rates. Results A total of 47 patients fit the inclusion criteria: 26 (55.3%) were male with a mean age of 7.87 ± 5.87 years. Overall, mortality was 31.9% (n = 15). When evaluating timing to DC, 36 (76.6%) patients were acute, and 11 (23.4%) were subacute. Acute DC patients presented with a lower Glasgow coma scale (5.02 ± 2.97) compared to subacute (8.45 ± 4.91) (P = 0.030). Timing of DC was not associated with GOS at discharge (P = 0.938), 3-month follow-up (P = 0.225), 6-month follow-up (P = 0.074), or complication rate (P = 0.505). The rate of posttraumatic hydrocephalus following DC for both groups was 6.4% (n = 3). Conclusion Although patients selected for the early DC had more severe injuries at presentation, there was no difference in outcomes. The optimal timing of DC requires a multifactorial approach considered on a case-by-case basis.
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Affiliation(s)
- Laszlo Nagy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Ryan D. Morgan
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Reagan A. Collins
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Abdurrahman F. Kharbat
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
| | - John Garza
- Department of Mathematics, University of Texas Permian Basin, Odessa, Texas, United States
| | - Muhittin Belirgen
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
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12
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Shim B, Stokum JA, Moyer M, Tsymbalyuk N, Tsymbalyuk O, Keledjian K, Ivanova S, Tosun C, Gerzanich V, Simard JM. Canagliflozin, an Inhibitor of the Na +-Coupled D-Glucose Cotransporter, SGLT2, Inhibits Astrocyte Swelling and Brain Swelling in Cerebral Ischemia. Cells 2023; 12:2221. [PMID: 37759444 PMCID: PMC10527352 DOI: 10.3390/cells12182221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Brain swelling is a major cause of death and disability in ischemic stroke. Drugs of the gliflozin class, which target the Na+-coupled D-glucose cotransporter, SGLT2, are approved for type 2 diabetes mellitus (T2DM) and may be beneficial in other conditions, but data in cerebral ischemia are limited. We studied murine models of cerebral ischemia with middle cerebral artery occlusion/reperfusion (MCAo/R). Slc5a2/SGLT2 mRNA and protein were upregulated de novo in astrocytes. Live cell imaging of brain slices from mice following MCAo/R showed that astrocytes responded to modest increases in D-glucose by increasing intracellular Na+ and cell volume (cytotoxic edema), both of which were inhibited by the SGLT2 inhibitor, canagliflozin. The effect of canagliflozin was studied in three mouse models of stroke: non-diabetic and T2DM mice with a moderate ischemic insult (MCAo/R, 1/24 h) and non-diabetic mice with a severe ischemic insult (MCAo/R, 2/24 h). Canagliflozin reduced infarct volumes in models with moderate but not severe ischemic insults. However, canagliflozin significantly reduced hemispheric swelling and improved neurological function in all models tested. The ability of canagliflozin to reduce brain swelling regardless of an effect on infarct size has important translational implications, especially in large ischemic strokes.
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Affiliation(s)
- Bosung Shim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Mitchell Moyer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Natalya Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Orest Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Svetlana Ivanova
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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13
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Truckenmueller P, Fritzsching J, Schulze D, Früh A, Jacobs S, Ahlborn R, Vajkoczy P, Prinz V, Hecht N. Outcome and management of decompressive hemicraniectomy in malignant hemispheric stroke following cardiothoracic surgery. Sci Rep 2023; 13:12994. [PMID: 37563196 PMCID: PMC10415332 DOI: 10.1038/s41598-023-40202-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023] Open
Abstract
Management of malignant hemispheric stroke (MHS) after cardiothoracic surgery (CTS) remains difficult as decision-making needs to consider severe cardiovascular comorbidities and complex coagulation management. The results of previous randomized controlled trials on decompressive surgery for MHS cannot be generally translated to this patient population and the expected outcome might be substantially worse. Here, we analyzed mortality and functional outcome in patients undergoing decompressive hemicraniectomy (DC) for MHS following CTS and assessed the impact of perioperative coagulation management on postoperative hemorrhagic and cardiovascular complications. All patients that underwent DC for MHS resulting as a complication of CTS between June 2012 and November 2021 were included in this observational cohort study. Outcome was determined according to the modified Rankin Scale (mRS) score at 1 and 3-6 months. Clinical and demographic data, anticoagulation management and postoperative hemorrhagic and thromboembolic complications were assessed. In order to evaluate a predictive association between clinical and radiological parameters and the outcome, we used a multivariate logistic regression analysis. Twenty-nine patients undergoing DC for MHS after CTS with a female-to-male ratio of 1:1.9 and a median age of 60 (IQR 49-64) years were identified out of 123 patients undergoing DC for MHS. Twenty-four patients (83%) received pre- or intraoperative substitution. At 30 days, the in-hospital mortality rate and neurological outcome corresponded to 31% and a median mRS of 5 (5-6), which remained stable at 3-6 months [Mortality: 42%, median mRS: 5 (4-6)]. Postoperatively, 15/29 patients (52%) experienced new hemorrhagic lesions and Bayesian logistic regression predicting mortality (mRS = 6) after imputing missing data demonstrated a significantly increased risk for mortality with longer aPPT (OR = 13.94, p = .038) and new or progressive hemorrhagic lesions after DC (OR = 3.03, p = .19). Notably, all but one hemorrhagic lesion occurred before discontinued anticoagulation and/or platelet inhibition was re-initiated. Despite perioperative discontinuation of anticoagulation and/or platelet inhibition, no coagulation-associated cardiovascular complications were noted. In conclusion, Cardiothoracic surgery patients suffering MHS will likely experience severe neurological disability after DC, which should remain a central aspect during counselling and decision-making. The complex coagulation situation after CTS, however, should not per se rule out the option of performing life-saving surgical decompression.
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Affiliation(s)
- Peter Truckenmueller
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Jonas Fritzsching
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Daniel Schulze
- Institute of Medical Biometrics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anton Früh
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Robert Ahlborn
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Vincent Prinz
- Department of Neurosurgery, Goethe Universität Frankfurt, Frankfurt am Main, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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14
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Truckenmueller P, Früh A, Wolf S, Faust K, Hecht N, Onken J, Ahlborn R, Vajkoczy P, Zdunczyk A. Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy. J Neurosurg 2023; 139:554-562. [PMID: 36681955 DOI: 10.3171/2022.10.jns221589] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/07/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC. METHODS The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2-5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema. RESULTS A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient's symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9-23) days in the drainage group compared with 13 (IQR 11-23) days in the control group (p = 0.21). CONCLUSIONS In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery.
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Affiliation(s)
| | - Anton Früh
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Stefan Wolf
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Katharina Faust
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Nils Hecht
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Julia Onken
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Robert Ahlborn
- 2Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Germany
| | - Peter Vajkoczy
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Anna Zdunczyk
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
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15
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Yamada SM, Iwamoto N, Tomita Y, Takeda R, Nakane M. Midline Shift Induced by the Drainage of Cerebrospinal Fluid in Three Patients With External Decompression. Cureus 2023; 15:e44355. [PMID: 37779764 PMCID: PMC10539714 DOI: 10.7759/cureus.44355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
It is not rare that progressive hydrocephalus worsens clinical conditions in a patient with external decompression and drainage or shunt surgery is required. However, spinal drainage or shunt surgeries potentially carry a risk of causing paradoxical herniation in a patient with decompressive craniectomy, particularly in a comatose case with wide craniectomy. Careful and strict observations are necessary for such patients. In our three comatose cases with craniectomy, paradoxical herniation occurred due to excessive drainage after 5-7 days of shunt surgery and lumbar drainage, although the drainage pressure was set at more than 10 cmH2O. Fortunately, in the three cases, the herniation improved within a few days after the drain was clamped and the bed was flattened. However, the Trendelenburg position and epidural blood patch might be necessary if paradoxical herniation occurs acutely after lumbar puncture or drainage because delayed resolution can be fatal in the herniation.
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Affiliation(s)
- Shoko M Yamada
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Naotaka Iwamoto
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Yusuke Tomita
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Ririko Takeda
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Makoto Nakane
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
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Früh A, Zdunczyk A, Wolf S, Mertens R, Spindler P, Wasilewski D, Hecht N, Bayerl S, Onken J, Wessels L, Faust K, Vajkoczy P, Truckenmueller P. Craniectomy size and decompression of the temporal base using the altered posterior question-mark incision for decompressive hemicraniectomy. Sci Rep 2023; 13:11419. [PMID: 37452076 PMCID: PMC10349086 DOI: 10.1038/s41598-023-37689-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023] Open
Abstract
The altered posterior question-mark incision for decompressive hemicraniectomy (DHC) was proposed to reduce the risk of intraoperative injury of the superficial temporal artery (STA) and demonstrated a reduced rate of wound-healing disorders after cranioplasty. However, decompression size during DHC is essential and it remains unclear if the new incision type allows for an equally effective decompression. Therefore, this study evaluated the efficacy of the altered posterior question-mark incision for craniectomy size and decompression of the temporal base and assessed intraoperative complications compared to a modified standard reversed question-mark incision. The authors retrospectively identified 69 patients who underwent DHC from 2019 to 2022. Decompression and preservation of the STA was assessed on postoperative CT scans and CT or MR angiography. Forty-two patients underwent DHC with the standard reversed and 27 patients with the altered posterior question-mark incision. The distance of the margin of the craniectomy to the temporal base was 6.9 mm in the modified standard reversed and 7.2 mm in the altered posterior question-mark group (p = 0.77). There was no difference between the craniectomy sizes of 158.8 mm and 158.2 mm, respectively (p = 0.45), and there was no difference in the rate of accidental opening of the mastoid air cells. In both groups, no transverse/sigmoid sinus was injured. Twenty-four out of 42 patients in the modified standard and 22/27 patients in the altered posterior question-mark group had a postoperative angiography, and the STA was preserved in all cases in both groups. Twelve (29%) and 5 (19%) patients underwent revision due to wound-healing disorders after DHC, respectively (p = 0.34). There was no difference in duration of surgery. Thus, the altered posterior question-mark incision demonstrated technically equivalent and allows for an equally effective craniectomy size and decompression of the temporal base without increasing risks of intraoperative complications. Previously described reduction in wound-healing complications and cranioplasty failures needs to be confirmed in prospective studies to demonstrate the superiority of the altered posterior question-mark incision.
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Affiliation(s)
- A Früh
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health, BIH Academy, Junior Digital Scientist Program, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - A Zdunczyk
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - S Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - R Mertens
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health, BIH Academy, Junior Clinician Scientist Program, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - P Spindler
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - D Wasilewski
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - N Hecht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - S Bayerl
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - J Onken
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - L Wessels
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - K Faust
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - P Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
| | - P Truckenmueller
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
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Marklund N, Brody DL. Refined Management of Severe Traumatic Brain Injury in Children. J Neurotrauma 2023; 40:1027-1028. [PMID: 37262426 DOI: 10.1089/neu.2021.29122.editorial] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
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18
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Moyer JD, Elouahmani S, Codorniu A, Abback PS, Jeantrelle C, Goutagny S, Gauss T, Sigaut S. External ventricular drainage for intracranial hypertension after traumatic brain injury: is it really useful? Eur J Trauma Emerg Surg 2023; 49:1227-1234. [PMID: 35169869 DOI: 10.1007/s00068-022-01903-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 01/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSES External ventricular drainage (EVD) is frequently used to control raised intracranial pressure after traumatic brain injury. However, the available evidence about its effectiveness in this context is limited. The aim of this study is to evaluate the effectiveness of EVD to control intracranial pressure and to identify the clinical and radiological factors associated with its success. METHODS For this retrospective cohort study conducted in a Level 1 traumacenter in Paris area between May 2011 and March 2019, all patients with intracranial hypertension and treated with EVD were included. EVD success was defined as an efficient and continuous control of intracranial hypertension avoiding the use of third tier therapies (therapeutic hypothermia, decompressive craniectomy, and barbiturate coma) or avoiding a decision to withdraw life sustaining treatment due to both refractory intracranial hypertension and severity of brain injury lesions. RESULTS 83 patients with EVD were included. EVD was successful in 33 patients (40%). Thirty-two patients (39%) required a decompressive craniectomy, eight patients (9%) received barbiturate coma. In ten cases (12%) refractory intracranial hypertension prompted a protocolized withdrawal of care. Complications occurred in nine patients (11%) (three cases of ventriculitis, six cases of catheter occlusion). Multivariate analysis identified no independent factors associated with EVD success. CONCLUSION In a protocol-based management for traumatic brain injury, EVD allowed intracranial pressure control and avoided third tier therapeutic measures in 40% of cases with a favorable risk-benefit ratio.
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Affiliation(s)
- Jean-Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France.
| | - Saida Elouahmani
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Anais Codorniu
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Paer-Selim Abback
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Caroline Jeantrelle
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Stéphane Goutagny
- Department of Neurosurgery, Assistance Publique Hôpitaux de Paris, Beaujon Hospital, Clichy, France
- Université de Paris, UFR de Médecine Paris Nord, Paris, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Stéphanie Sigaut
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
- Université de Paris, UFR de Médecine Paris Nord, Paris, France
- NeuroDiderot, Inserm U1141, Université de Paris, Paris, France
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Lehrieder D, Müller HP, Kassubek J, Hecht N, Thomalla G, Michalski D, Gattringer T, Wartenberg KE, Schultze-Amberger J, Huttner H, Kuramatsu JB, Wunderlich S, Steiner HH, Weissenborn K, Heck S, Günther A, Schneider H, Poli S, Dohmen C, Woitzik J, Jüttler E, Neugebauer H. Large diameter hemicraniectomy does not improve long-term outcome in malignant infarction. J Neurol 2023:10.1007/s00415-023-11766-3. [PMID: 37162579 DOI: 10.1007/s00415-023-11766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION In malignant cerebral infarction decompressive hemicraniectomy has demonstrated beneficial effects, but the optimum size of hemicraniectomy is still a matter of debate. Some surgeons prefer a large-sized hemicraniectomy with a diameter of more than 14 cm (HC > 14). We investigated whether this approach is associated with reduced mortality and an improved long-term functional outcome compared to a standard hemicraniectomy with a diameter of less than 14 cm (HC ≤ 14). METHODS Patients from the DESTINY (DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY) registry who received hemicraniectomy were dichotomized according to the hemicraniectomy diameter (HC ≤ 14 cm vs. HC > 14 cm). The primary outcome was modified Rankin scale (mRS) score ≤ 4 after 12 months. Secondary outcomes were in-hospital mortality, mRS ≤ 3 and mortality after 12 months, and the rate of hemicraniectomy-related complications. The diameter of the hemicraniectomy was examined as an independent predictor of functional outcome in multivariable analyses. RESULTS Among 130 patients (32.3% female, mean (SD) age 55 (11) years), the mean hemicraniectomy diameter was 13.6 cm. 42 patients (32.3%) had HC > 14. There were no significant differences in the primary outcome and mortality by size of hemicraniectomy. Rate of complications did not differ (HC ≤ 14 27.6% vs. HC > 14 36.6%, p = 0.302). Age and infarct volume but not hemicraniectomy diameter were associated with outcome in multivariable analyses. CONCLUSION In this post-hoc analysis, large hemicraniectomy was not associated with an improved outcome or lower mortality in unselected patients with malignant middle cerebral artery infarction. Randomized trials should further examine whether individual patients could benefit from a large-sized hemicraniectomy. CLINICAL TRIAL REGISTRATION INFORMATION German Clinical Trials Register (URL: https://www.drks.de ; Unique Identifier: DRKS00000624).
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Affiliation(s)
- Dominik Lehrieder
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
| | | | - Jan Kassubek
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Michalski
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | | | - Katja E Wartenberg
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
- Department of Neurology, University of Halle-Wittenberg, Halle/Saale, Germany
| | | | - Hagen Huttner
- Department of Neurology, University Hospital Giessen, Giessen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Silke Wunderlich
- Department of Neurology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Suzette Heck
- Department of Neurology, University of Munich, Ludwig Maximilian University, Munich, Germany
| | - Albrecht Günther
- Department of Neurology, University Hospital Jena, Jena, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Sven Poli
- Department of Neurology and Stroke, Eberhard-Karls University Tuebingen, Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Christian Dohmen
- Department of Neurology, University Hospital Cologne, Cologne, Germany
- Department for Neurology and Neurological Intensive Care, LVR Clinic Bonn, Bonn, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, University Hospital Oldenburg, Oldenburg, Germany
| | - Eric Jüttler
- Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
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20
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Ahmed AK, Jagtiani P, Jones S. Technical Optimization of Decompressive Craniectomy for Possible Conversion to Hinge Craniotomy in Traumatic Brain Injury. Cureus 2023; 15:e39767. [PMID: 37398770 PMCID: PMC10312037 DOI: 10.7759/cureus.39767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Hinge craniotomy for the management of elevated intracranial pressure (ICP) in traumatic brain injury remains a technique not widely adopted. The hinged bone flap decreases the allowable intracranial volume expansion, which can lead to persistent post-operative elevated ICP and the need for salvage craniectomy. Herein, we describe the technical nuances in performing a decompressive craniectomy that, when optimized, allows for stronger consideration for hinge craniotomy as a definitive technique. To conclude, hinge craniotomy is a reasonable option in the setting of traumatic brain injury. Trauma neurosurgeons can consider the technical steps to optimize a decompressive craniectomy and perform hinge craniotomy when allowable.
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Affiliation(s)
| | - Pemla Jagtiani
- Medical School, State University of New York Downstate Health Sciences University, New York, USA
| | - Salazar Jones
- Neurological Surgery, Mount Sinai Hospital, New York, USA
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21
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Han W, Song Y, Rocha M, Shi Y. Ischemic brain edema: Emerging cellular mechanisms and therapeutic approaches. Neurobiol Dis 2023; 178:106029. [PMID: 36736599 DOI: 10.1016/j.nbd.2023.106029] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/14/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Brain edema is one of the most devastating consequences of ischemic stroke. Malignant cerebral edema is the main reason accounting for the high mortality rate of large hemispheric strokes. Despite decades of tremendous efforts to elucidate mechanisms underlying the formation of ischemic brain edema and search for therapeutic targets, current treatments for ischemic brain edema remain largely symptom-relieving rather than aiming to stop the formation and progression of edema. Recent preclinical research reveals novel cellular mechanisms underlying edema formation after brain ischemia and reperfusion. Advancement in neuroimaging techniques also offers opportunities for early diagnosis and prediction of malignant brain edema in stroke patients to rapidly adopt life-saving surgical interventions. As reperfusion therapies become increasingly used in clinical practice, understanding how therapeutic reperfusion influences the formation of cerebral edema after ischemic stroke is critical for decision-making and post-reperfusion management. In this review, we summarize these research advances in the past decade on the cellular mechanisms, and evaluation, prediction, and intervention of ischemic brain edema in clinical settings, aiming to provide insight into future preclinical and clinical research on the diagnosis and treatment of brain edema after stroke.
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Affiliation(s)
- Wenxuan Han
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Yang Song
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Marcelo Rocha
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America
| | - Yejie Shi
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, United States of America.
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22
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Berra LV, Cedrone G, Di Norcia V, D'Angelo L, Brunetto F, Familiari P, Palmieri M, Capobianco M, Pappone F, Santoro A. Development of a Novel Device for Decompressive Craniectomy: An Experimental and Cadaveric Study and Preliminary Clinical Application. Oper Neurosurg (Hagerstown) 2023; 24:324-330. [PMID: 36701747 DOI: 10.1227/ons.0000000000000530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 09/20/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Decompressive craniectomy is an intervention of established efficacy in patients with intractable cerebral edema. OBJECTIVE To evaluate a new device used in alternative to decompressive craniectomy. This device is designed to perform an augmentative craniotomy by keeping the bone flap elevated using specific cranial suspension titanium plates and giving the brain enough room to swell. METHODS We tested the mechanical characteristics of the cranial brackets on dried skulls, on 3D-printed skull models, and on a preserved cadaver head. The resistance of the device was examined through dynamometric testing, and the feasibility of the surgical technique, including the suspension of the bone flap and the skin closure, was investigated on the cadaveric model. A preliminary clinical series of 2 patients is also reported. RESULTS The laboratory tests have shown that this system allows an adequate expansion of the intracranial volume and it could withstand a force up to 637 ± 13 N in the synthetic model and up to 658 ± 9 N in the human skull without dislocation or failure of the brackets nor fractures of the bone ridges. Preliminary application in the clinical setting has shown that augmentative craniotomy is effective in the control of intracranial hypertension and could reduce the costs and complications associated with the classical decompressive craniectomy technique. CONCLUSION Preliminary laboratory and clinical results show augmentative craniotomy to be a promising, alternative technique to decompressive craniectomy. Further clinical studies will be needed to validate its efficacy.
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Affiliation(s)
- Luigi Valentino Berra
- Department of Neurosurgery, Policlinico Umberto I, Sapienza Università di Roma, Roma, Italy
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23
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Size of Craniectomy Predicts Approach-Related Shear Bleeding in Poor-Grade Subarachnoid Hemorrhage. Brain Sci 2023; 13:brainsci13030371. [PMID: 36979181 PMCID: PMC10046376 DOI: 10.3390/brainsci13030371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Decompressive craniectomy is an option to decrease elevated intracranial pressure in poor-grade aneurysmal subarachnoid hemorrhage (SAH) patients. The aim of the present study was to analyze the size of the bone flap according to approach-related complications in patients with poor-grade SAH. We retrospectively analyzed poor-grade SAH patients (WFNS 4 and 5) who underwent aneurysm clipping and craniectomy (DC or ommitance of bone flap reinsertion). Postoperative CT scans were analyzed for approach-related tissue injury at the margin of the craniectomy (shear bleeding). The size of the bone flap was calculated using the De Bonis equation. Between 01/2012 and 01/2020, 67 poor-grade SAH patients underwent clipping and craniectomy at our institution. We found 14 patients with new shear bleeding lesion in postoperative CT scan. In patients with shear bleeding, the size of the bone flap was significantly smaller compared to patients without shear bleeding (102.1 ± 45.2 cm2 vs. 150.8 ± 37.43 cm2, p > 0.0001). However, we found no difference in mortality rates (10/14 vs. 23/53, p = 0.07) or number of implanted VP shunts (2/14 vs. 18/53, p = 0.2). We found no difference regarding modified Rankin Scale (mRS) 6 months postoperatively. In poor-grade aneurysmal SAH, the initial planning of DC—if deemed necessary —and enlargement of the flap size seems to decrease the rate of postoperatively developed shear bleeding lesions.
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24
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Fallatah MA, Aldahlawi A, Babateen EM, Saif S, Alnejadi W, Bamsallm M, Lary A. Outcomes of Cranioplasty: A Single-Center Experience. Cureus 2023; 15:e35213. [PMID: 36968927 PMCID: PMC10035764 DOI: 10.7759/cureus.35213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 02/22/2023] Open
Abstract
Background Cranioplasty (CP) is a common cranial reconstructive procedure. It is performed after craniectomy due to various causes such as relieving increased intracranial pressure, infection, and tumor infiltration. Although CP is an easy procedure, it is associated with a high rate of complications. We aimed to retrospectively investigate the outcomes of CP at the King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah (KAMC-J). Methods This is a retrospective observational study that included all patients who had CP (first time or redo) at KAMC-J from 1st January 2010 to 31st December 2020. Patients with congenital cranial malformation were excluded. Result A total of 68 patients underwent CP. Of those, 23 (34%) had complications. The most common complication was infection (10.3%). Twelve of the 23 patients had major complications that necessitated reoperation. Of those 12, six underwent redo CP; three out of these six patients had further complications which were also managed surgically. On bivariate analysis, cranial defects over 50 cm² were associated with a higher rate of both infection and hydrocephalus (p=0.018) while the frontal site was associated with a higher rate of infection (p=0.014). Moreover, traumatic brain injury as an etiology was exclusively associated with post-cranioplasty hydrocephalus (p=0.03). Conclusion Patients undergoing CP after craniectomy are prone to a considerably high rate of adverse outcomes. The overall rate of complications in this study was 34%, with an infection rate of 10.3% and a 1.5% mortality rate. Consistent with other studies, larger cranial defects as well as frontal sites have a higher rate of infection.
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25
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Kumarasamy S, Garg K, Gurjar HK, Praneeth K, Meena R, Doddamani R, Kumar A, Mishra S, Tandon V, Singh P, Agrawal D. Complications of Decompressive Craniectomy: A Case-Based Review. INDIAN JOURNAL OF NEUROTRAUMA 2023. [DOI: 10.1055/s-0043-1760724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Abstract
Background Decompressive craniectomy (DC) is a frequently performed procedure to treat intracranial hypertension following traumatic brain injury (TBI) and stroke. DC is a salvage procedure that reduces mortality at the expense of severe disability and compromises the quality of life. The procedure is not without serious complications.
Methods We describe the complications following DC and its management in a case-based review in this article.
Results Complications after DC are classified as early or late complications based on the time of occurrence. Early complication includes hemorrhage, external cerebral herniation, wound complications, CSF leak/fistula, and seizures/epilepsy. Contusion expansion, new contralateral epidural, and subdural hematoma in the immediate postoperative period mandate surgical intervention. It is necessary to repeat non-contrast CT head at 24 hours and 48 hours following DC. Late complication includes subdural hygroma, hydrocephalus, syndrome of the trephined, bone resorption, and falls on the unprotected cranium. An early cranioplasty is an effective strategy to mitigate most of the late complications.
Conclusions DC can be associated with a number of complications. One should be aware of the possible complications, and timely intervention is required.
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Affiliation(s)
- Sivaraman Kumarasamy
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Hitesh Kumar Gurjar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Kokkula Praneeth
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Meena
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ramesh Doddamani
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Amandeep Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashwat Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Tandon
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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26
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Kumar P, Srivastava C, Bajaj A, Yadav A, Krishna Ojha B. A prospective, randomized, controlled study comparing two surgical procedures of decompressive craniectomy in patients with traumatic brain injury: Dural closure without dural closure. J Clin Neurosci 2023; 108:30-36. [PMID: 36580858 DOI: 10.1016/j.jocn.2022.11.015] [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: 08/31/2022] [Revised: 11/08/2022] [Accepted: 11/27/2022] [Indexed: 12/28/2022]
Abstract
Decompressive craniectomy (DC) is used to treat severe traumatic brain injury [TBI]. The present study compared dural open and closed surgical procedures for DC and their relationship with Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (E) (GOS-E) scores and survival in prospective randomized controlled TBI patients. Patients aged 10-65 (36.97 ± 13.23) with DC were hospitalized in the neurotrauma unit of King George's Medical University, Lucknow, India. The patients were randomized into test; with dural closure (n = 60) and control without dural closure (OD) (n = 60) groups. After decompressive craniectomy, patients were monitored daily until hospital discharge or death and for three months. GSC/E leakage, infection, and functional status were also assessed. Age (p = 0.795), sex (p = 0.104), mode of injury (p = 0.195), GCS score (p = 0.40, p = 0.469), Rotterdam score (p = 0.731), and preoperative midline shift (MLS) (p = 0.378) did not vary between the OD and CD groups. Neither technique affected the mortality, motor score, or pupil response (p > 0.05). After one and three months, GOS extension was associated with open and closed dural procedures (p = 0.089). Intracranial pressure, brain bulge, GCS score, and MLS were not associated with theoperative method(p > 0.05). The open dural group had a significantly shorter procedure time than the closed dural group (P = 0.026). Both groups showed no significant difference (p > 0.05) between CSF leak and post-traumatic hydrocephalus. Dural opensurgery for a compressed craniectomy is shorter and not associated with significant surgical consequences compared to close dural close surgery.
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Affiliation(s)
- Pankaj Kumar
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India
| | - Chhitij Srivastava
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India.
| | - Ankur Bajaj
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India
| | - Awadhesh Yadav
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India
| | - Bal Krishna Ojha
- Department of Neurosurgery, King George's Medical University, Lucknow 226003, India
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Decompressive hemicraniectomy versus medical treatment for malignant middle cerebral artery infarction: Eleven years experience in a Tunisian center. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Xu L, Xiong Y, Guo J, Tang W, Wong KKL, Yi Z. An intelligent system for craniomaxillofacial defecting reconstruction. INT J INTELL SYST 2022. [DOI: 10.1002/int.23006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lei Xu
- Machine Intelligence Laboratory, College of Computer Science Sichuan University People's Republic of China
| | - Yutao Xiong
- Department of Oral and Maxillofacial Surgery, West China College of Stomatology Sichuan University Chengdu People's Republic of China
| | - Jixiang Guo
- Machine Intelligence Laboratory, College of Computer Science Sichuan University People's Republic of China
| | - Wei Tang
- Department of Oral and Maxillofacial Surgery, West China College of Stomatology Sichuan University Chengdu People's Republic of China
| | - Kelvin K. L. Wong
- The University of Adelaide Adelaide Australia
- School of Computer Science and Engineering Central South University Changsha People's Republic of China
| | - Zhang Yi
- Machine Intelligence Laboratory, College of Computer Science Sichuan University People's Republic of China
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Bedside Ultrasound for Ventricular Size Monitoring in Patients with PEEK Cranioplasty: A Preliminary Experience of Technical Feasibility in Neurotrauma Setting. Neurocrit Care 2022; 37:705-713. [PMID: 35761126 DOI: 10.1007/s12028-022-01544-w] [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: 02/03/2022] [Accepted: 06/01/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Posttraumatic hydrocephalus is a known complication after traumatic brain injury, particularly affecting patients undergoing decompressive craniectomy. Posttraumatic hydrocephalus monitoring in these patients represents a common issue in neurosurgical practice. Patients require periodical assessments by means of computed tomography (CT) scans. This study presents a preliminary institutional series in which ultrasound was used as a bedside imaging technique to monitor ventricular size in patients harboring a polyetheretherketone (PEEK) cranioplasty. Exploiting the PEEK cranioplasty permeability to echoes, we evaluated the feasibility of this bedside imaging method in monitoring hydrocephalus evolution, determining effects of ventriculo-peritoneal shunt, and excluding complications. METHODS Eight patients with traumatic brain injury harboring PEEK cranioplasty following decompressive craniectomy were prospectively evaluated. Ultrasound measurements were compared with CT scan data taken the same day, and ventricular morphometry parameters were compared. RESULTS Ultrasound images through the PEEK cranioplasty were of high quality and intracranial anatomy was distinctly evaluated. A strong correlation was observed between ultrasound and CT measurements. Concerning distance between lateral ventricles frontal horns (IFH) and the diameter of the third ventricle (TV), we found a strong correlation between transcranial sonography and CT measurements in preventriculoperitoneal shunt (rho = 0.92 and p = 0.01 for IFH; rho = 0.99 and p = 0.008 for TV) and in postventriculoperitoneal shunt examinations (rho = 0.95 and p = 0.03 for IFH; rho = 0.97 and p = 0.03 for TV). The mean error rate between transcranial sonography and CT scan was 1.77 ± 0.91 mm for preoperative IFH, 0.65 ± 0.27 mm for preoperative TV, 2.18 ± 0.82 mm for postoperative IFH, and 0.48 ± 0.21 mm for postoperative TV. CONCLUSIONS Transcranial ultrasound could represent a simplification of the follow-up and management of ventricular size of patients undergoing PEEK cranioplasty. Even if this is a small series, our preliminary results could widen the potential benefits of PEEK, not only as effective material for cranial reconstruction but also, in selected clinical conditions, as a reliable window to explore intracranial content and to monitor ventricular sizes and shunt functioning.
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Cardali SM, Caffo M, Caruso G, Scalia G, Gorgoglione N, Conti A, Vinci SL, Barresi V, Granata F, Ricciardo G, Garufi G, Raffa G, Germanò A. Cisternostomy for malignant middle cerebral artery infarction: proposed pathophysiological mechanisms and preliminary results. Stroke Vasc Neurol 2022; 7:476-481. [PMID: 35672081 PMCID: PMC9811554 DOI: 10.1136/svn-2021-000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/16/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The ischaemic stroke of the territory of the middle cerebral artery represents an event burdened by high mortality and severe morbidity. The proposed medical treatments do not always prove effective. Decompressive craniectomy allows the ischaemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. In this study, we propose a novel treatment for these patients characterised by surgical fenestration of the cisterns of the skull base. METHODS We have treated 16 patients affected by malignant middle cerebral artery ischaemia and treated with cisternostomy between August 2018 and December 2019. The clinical history, neurological examination findings and neuroradiological studies (brain CT, CT angiography, MRI) were performed to diagnose stroke. Clinical examination was recorded on admission and preoperatively using the Glasgow Coma Scale and the National Institutes of Health Stroke Scale. RESULTS The study included 16 patients, 10 males and 6 females. The mean age at surgery was 60.1 years (range 19-73). Surgical procedure was performed in all patients. The patients underwent immediate postoperative CT scan and were in the early hours evaluated in sedation window. In total, we recorded two deaths (12.5%). A functional outcome between mRS 0-3, defined as favourable, was observed in 9 (64.2%) patients 9 months after discharge. A functional outcome between mRS 4-6, defined as poor, was observed in 5 (35.7%) patients 9 months after discharge. CONCLUSIONS The obtained clinical results appear, however, substantially overlapping to decompressive craniectomy. Cisternostomy results in a favourable functional outcome after 9 months. This proposed technique permits that the patient no longer should be undergone cranioplasty thus avoiding the possible complications related to this procedure. The results are certainly interesting but higher case numbers are needed to reach definitive conclusions.
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Affiliation(s)
- Salvatore Massimiliano Cardali
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Maria Caffo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Gerardo Caruso
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Gianluca Scalia
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Nicola Gorgoglione
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Alfredo Conti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Sergio Lucio Vinci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neuroradiology, University of Messina, Messina, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Anatomic Pathology, University of Verona, Verona, Italy
| | - Francesca Granata
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neuroradiology, University of Messina, Messina, Italy
| | - Giuseppe Ricciardo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Giada Garufi
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Giovanni Raffa
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Antonino Germanò
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
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Cai Z, Zhao K, Li Y, Wan X, Li C, Niu H, Shu K, Lei T. Early Enteral Nutrition Can Reduce Incidence of Postoperative Hydrocephalus in Patients with Severe Hypertensive Intracerebral Hemorrhage. Med Sci Monit 2022; 28:e935850. [PMID: 35655416 PMCID: PMC9172265 DOI: 10.12659/msm.935850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hydrocephalus secondary to hypertensive intracerebral hemorrhage (HICH) dramatically affects the prognosis. Early enteral nutrition (EN) is beneficial to severe HICH patients, but the impact of early EN administration on hydrocephalus remains unknown. This study aimed to explore the predictors for hydrocephalus occurrence after HICH, with special focus on the effect of early EN application. MATERIAL AND METHODS We retrospectively analyzed 146 patients with severe HICH who underwent microsurgery between January 2014 and October 2019 in our department. Patients were divided into early EN (≤48 h) and delayed EN (>48 h) group according to the time-point of EN administration. The diagnosis of hydrocephalus was confirmed by both radiological evaluation and an Evan index method. Diagnosis confirmed within 2 weeks after HICH was identified as acute hydrocephalus, otherwise, it was considered as chronic hydrocephalus. RESULTS Twenty-seven patients experienced acute hydrocephalus, while 20 patients developed chronic hydrocephalus. Low preoperative Glasgow coma scale (GCS), subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), delayed EN administration, high levels of postoperative white blood cell, neutrophil, neutrophil-to-lymphocyte ratio, C-reactive protein (CRP), and lactate dehydrogenase were positively related to the occurrence of chronic hydrocephalus (p<0.05), while only IVH was correlated with acute hydrocephalus occurrence (p<0.05). In addition, a multivariate analysis demonstrated that preoperative GCS, SAH, IVH, and early EN administration (p<0.05) were independent predictors for chronic hydrocephalus occurrence. CONCLUSIONS Early EN administration, SAH, IVH, and preoperative GCS were associated with the occurrence of chronic hydrocephalus in severe HICH patients. Early EN administration may inhibit the inflammatory response of brain-gut axis, which in turn reduces chronic hydrocephalus occurrence.
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Vychopen M, Schneider M, Borger V, Schuss P, Behning C, Vatter H, Güresir E. Complete hemispheric exposure vs. superior sagittal sinus sparing craniectomy: incidence of shear-bleeding and shunt-dependency. Eur J Trauma Emerg Surg 2022; 48:2449-2457. [PMID: 34605961 PMCID: PMC9192399 DOI: 10.1007/s00068-021-01789-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Decompressive hemicraniectomy (DC) has been established as a standard therapeutical procedure for raised intracranial pressure. However, the size of the DC remains unspecified. The aim of this study was to analyze size related complications following DC. METHODS Between 2013 and 2019, 306 patients underwent DC for elevated intracranial pressure at author´s institution. Anteroposterior and craniocaudal DC size was measured according to the postoperative CT scans. Patients were divided into two groups with (1) exposed superior sagittal sinus (SE) and (2) without superior sagittal sinus exposure (SC). DC related complications e.g. shear-bleeding at the margins of craniectomy and secondary hydrocephalus were evaluated and compared. RESULTS Craniectomy size according to anteroposterior diameter and surface was larger in the SE group; 14.1 ± 1 cm vs. 13.7 ± 1.2 cm, p = 0.003, resp. 222.5 ± 40 cm2 vs. 182.7 ± 36.9 cm2, p < 0.0001. The SE group had significantly lower rates of shear-bleeding: 20/176 patients; (11%), compared to patients of the SC group; 36/130 patients (27%), p = 0.0003, OR 2.9, 95% CI 1.6-5.5. There was no significant difference in the incidence of shunt-dependent hydrocephalus; 19/130 patients (14.6%) vs. 24/176 patients (13.6%), p = 0.9. CONCLUSIONS Complete hemispheric exposure in terms of DC with SE was associated with significantly lower levels of iatrogenic shear-bleedings compared to a SC-surgical regime. Although we did not find significant outcome difference, our findings suggest aggressive craniectomy regimes including SE to constitute the surgical treatment strategy of choice for malignant intracranial pressure.
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Affiliation(s)
- Martin Vychopen
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Charlotte Behning
- Department of Medical Biometry, Informatics and Epidemiology, Universität Bonn, Institut für Medizinische Biometrie, Informatik und Epidemiologie (IMBIE), Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
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Papaioannou V, Czosnyka Z, Czosnyka M. Hydrocephalus and the neuro-intensivist: CSF hydrodynamics at the bedside. Intensive Care Med Exp 2022; 10:20. [PMID: 35618965 PMCID: PMC9135922 DOI: 10.1186/s40635-022-00452-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/19/2022] [Indexed: 12/05/2022] Open
Abstract
Hydrocephalus (HCP) is far more complicated than a simple disorder of cerebrospinal fluid (CSF) circulation. HCP is a common complication in patients with subarachnoid hemorrhage (SAH) and after craniectomy. Clinical measurement in HCP is mainly related to intracranial pressure (ICP) and cerebral blood flow. The ability to obtain quantitative variables that describe CSF dynamics at the bedside before potential shunting may support clinical intuition with a description of CSF dysfunction and differentiation between normal pressure hydrocephalus and brain atrophy. This review discusses the advanced research on HCP and how CSF is generated, stored and absorbed within the context of a mathematical model developed by Marmarou. Then, we proceed to explain the main quantification analysis of CSF dynamics using infusion techniques for deciding on definitive treatment. We consider that such descriptions of multiple parameters of measurements need to be significantly appreciated by the caring neuro-intensivist, for better understanding of the complex pathophysiology and clinical management and finally, improve of the prognosis of these patients with HCP. In this review article, we present current and novel theories of CSF circulation and pathophysiology of hydrocephalus, along with results from infusion studies for evaluating CSF dynamics at the bedside.
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Affiliation(s)
- Vasilios Papaioannou
- Department of Intensive Care Medicine, Alexandroupolis Hospital, Democritus University of Thrace, 68100, Alexandroupolis, Greece. .,Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, P.O. Box 167, CB20QQ, Cambridge, UK. .,Department of Intensive Care Medicine, Alexandroupolis Hospital, Democritus University of Thrace, Polyviou 6-8, 55132, Thessaloniki, Greece.
| | - Zofia Czosnyka
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, P.O. Box 167, CB20QQ, Cambridge, UK
| | - Marek Czosnyka
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, P.O. Box 167, CB20QQ, Cambridge, UK
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Liu Z, Du S, Wu Y, Chen T, Luo X, Bi C, Lan S, Chen X, Liu J. Intracranial pressure after closure of dura predicts decompressive craniectomy in patients with head trauma. J Neurotrauma 2022; 39:1231-1239. [PMID: 35538792 DOI: 10.1089/neu.2021.0499] [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: 11/12/2022] Open
Abstract
This study aimed to address the risk factors of second decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) who initially underwent mass lesion evacuation, but no primary DC. Patients were enrolled if they had a hospital visit to Xiangya Hospital, Central South University with acute closed TBI from January 1, 2017, to December 31, 2019, and had undergone craniotomic mass lesion evacuation. Socio-demographic information, computed tomography (CT) information, clinical profiles, and surgical information were obtained from an electronic database. Twenty-four patients who had undergone a second DC (SDC) and 39 patients who did not (NSO) were included in the analysis. The prevailing lesions differed between the groups (P = 0.010). The SDC group had more compressed/obliterated basal cisterns than the NSO group (P = 0.028). After closure of dura, the SDC group also had higher intracranial pressure (ICP) than the NSO group (10.9 mmHg vs. 6.5 mmHg, P = 0.005). Binary logistic regression indicated that ICP after dura closure was an independent predictor of second DC (OR = 1.317, P = 0.011). A model using ICP after dura closure alone had an area under the curve value of 0.757 in its receiver operating characteristic curve. An ICP above 10.5 mmHg after closure of dura for the prediction of second DC had a sensitivity of 56.3% and specificity of 92.6%.
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Affiliation(s)
- Ziyuan Liu
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, No.87 Xiangya Road, Changsha, China, 410008;
| | - Shan Du
- Xiangya Hospital Central South University, 159374, Department of Gastroenterology, Changsha, China;
| | - Yun Wu
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, China;
| | - Tiange Chen
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, China;
| | - Xiangying Luo
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, China;
| | - Changlong Bi
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, No.87 Xiangya Road, Changsha, China, 410008;
| | - Song Lan
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, No.87 Xiangya Road, Changsha, China, 410008;
| | - Xin Chen
- Xiangya Hospital Central South University, 159374, Neurosurgery, Changsha, Hunan, China.,Xiangya Hospital Central South University, 159374, National Clinical Medical Research Center for Geriatric Diseases, Changsha, Hunan, China;
| | - Jinfang Liu
- Xiangya Hospital Central South University, 159374, Department of Neurosurgery, Changsha, Hunan, China.,Xiangya Hospital Central South University, 159374, National Clinical Medical Research Center for Geriatric Diseases, Changsha, Hunan, China;
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Evaluation of the Fitting Accuracy of CAD/CAM-Manufactured Patient-Specific Implants for the Reconstruction of Cranial Defects-A Retrospective Study. J Clin Med 2022; 11:jcm11072045. [PMID: 35407653 PMCID: PMC9000016 DOI: 10.3390/jcm11072045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/02/2022] [Accepted: 04/04/2022] [Indexed: 02/04/2023] Open
Abstract
Cranioplasties show overall high complication rates of up to 45.3%. Risk factors potentially associated with the occurrence of postoperative complications are frequently discussed in existing research. The present study examines the positioning of 39 patient-specific implants (PSI) made from polyetheretherketone (PEEK) and retrospectively investigates the relationship between the fitting accuracy and incidence of postoperative complications. To analyze the fitting accuracy of the implants pre- and post-operatively, STL files were created and superimposed in a 3D coordinate system, and the deviations were graphically displayed and evaluated along with the postoperative complications. On average, 95.17% (SD = 9.42) of the measurements between planned and surgically achieved implant position were within the defined tolerance range. In cases with lower accordance, an increased occurrence of complications could not be demonstrated. The overall postoperative complication rate was 64.1%. The fitting of the PEEK-PSI was highly satisfactory. There were predominantly minor deviations of the achieved compared to the planned implant positions; however, estimations were within the defined tolerance range. Despite the overall high accuracy of fitting, a considerable complication rate was found. To optimize the surgical outcome, the focus should instead be directed towards the investigation of other risk factors.
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Twitter Journal Club Impact on Engagement Metrics of the Neurocritical Care Journal. Neurocrit Care 2022; 37:129-139. [PMID: 35237920 DOI: 10.1007/s12028-022-01458-7] [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: 12/30/2020] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Twitter journal clubs are a modern way of highlighting articles published in a scientific journal. The Neurocritical Care journal (NCC) initiated a bimonthly, Twitter-based, online journal club in 2015 to increase the outreach of its published articles. We hypothesize that articles included in the Neurocritical Care Society Twitter Journal Club (NCSTJC) had greater engagement than other articles published during the same time period. We also investigated the relationship between number of citations and Altmetric score to assess whether the enhanced online activity resulted in higher citations. METHODS We gathered data in August 2020 on engagement metrics (number of downloads, Altmetric score, relative citation ratio, and number of citations) of all articles published in NCC between 2015 and 2018. Articles were analyzed into two groups: one featured in NCSTJC and the rest that were not (non-NCSTJC1), and the other comprised those that were not in NCSTJC but published under a similar category of articles as NCSTJC (non-NCSTJC2). Results were analyzed using descriptive statistics, and summary measures were used to report the spread. The groups were compared by using the Wilcoxon rank sum test, given that the data were not normally distributed. Spearman's rank correlation was used to assess correlation between Altmetric score and citations for the articles in the NCSTJC and non-NCSTJC groups. For comparison, the top ten cited articles in NCC were analyzed for similar correlations. RESULTS Between 2015 and 2018, NCC published 529 articles, 24 of which were included in the Twitter journal club. A total of 406 articles were published in the same category as the category of articles selected for NCSTJC. The articles discussed as a part of NCSTJC had a statistically significant trend toward a higher number of downloads, Altmetric score, relative citation ratio, and number of citations than rest of the articles published in the journal during the same time period and the rest of the articles published in same categories. Three NCSTJC articles were among the ten most-cited articles published by NCC between 2015 and 2018. We did not find a correlation between Altmetric scores and number of citations in the NCSTJC or non-NCSTJC1 or non-NCSTJC2 group, but there was a strong correlation between these two variables in high performing articles when the top ten cited articles were analyzed. CONCLUSIONS Scientific journals are evolving their social media strategies in attempt to increase the outreach of their articles to the medical community. Platforms such as Twitter journal clubs can enhance such engagement. The long-term influence of such strategies on the impact factor of a medical journal and traditional engagement metrics, such as citations, calls for further research.
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Decompressive Craniectomy for Stroke: Who, When, and How. Neurol Clin 2022; 40:321-336. [DOI: 10.1016/j.ncl.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Pang SSY, Fang E, Chen KW, Leung M, Chow VLY, Fang C. Patient-specific 3D-printed helmet for post-craniectomy defect - a case report. 3D Print Med 2022; 8:4. [PMID: 35089457 PMCID: PMC8796519 DOI: 10.1186/s41205-022-00131-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 01/17/2022] [Indexed: 11/23/2022] Open
Abstract
Background Patients who undergo decompressive craniectomy (DC) are often fitted with a helmet that protects the craniectomy site from injury during rehabilitation. However, conventional “one-size-fits-all” helmets may not be feasible for certain craniectomy defects. We describe the production and use of a custom 3D-printed helmet for a DC patient where a conventional helmet was not feasible due to the craniectomy defect configuration. Case presentation A 65-year-old male with ethmoid sinonasal carcinoma underwent cranionasal resection and DC with free vastus lateralis flap reconstruction to treat cerebrospinal fluid leakage. He required an external helmet to protect the craniectomy site, however, the rim of a conventional helmet compressed the craniectomy site, and the straps compressed the vascular pedicle of the muscle flap. Computed topography (CT) scans of the patient’s cranium were imported into 3D modelling software and used to fabricate a patient-specific, strapless helmet using fused deposition modelling (FDM). The final helmet fit the patient perfectly and circumvented the compression issues, while also providing better cosmesis than the conventional helmet. Four months postoperatively, the helmet remains intact and in use. Conclusions 3D printing can be used to produce low-volume, patient-specific external devices for rehabilitation where standardized adjuncts are not optimal. Once initial start-up costs and training are overcome, these devices can be produced by surgeons themselves to meet a wide range of clinical needs.
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Affiliation(s)
- Sherby Suet-Ying Pang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Evan Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China.
| | - Kam Wai Chen
- Prosthetics and Orthotics Department, Queen Mary Hospital, Hong Kong, China
| | - Matthew Leung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China
| | - Velda Ling-Yu Chow
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Christian Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong, China
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Histological Processing of CAD/CAM Titanium Scaffold after Long-Term Failure in Cranioplasty. MATERIALS 2022; 15:ma15030982. [PMID: 35160928 PMCID: PMC8839919 DOI: 10.3390/ma15030982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/17/2022] [Accepted: 01/25/2022] [Indexed: 02/01/2023]
Abstract
Cranioplasty is a frequently performed procedure after craniectomy and includes several techniques with different materials. Due to high overall complication rates, alloplastic implants are removed in many cases. Lack of implant material osseointegration is often assumed as a reason for failure, but no study has proven this in cranioplasty. This study histologically evaluates the osteointegration of a computer-aided design and computer-aided manufacturing (CAD/CAM) titanium scaffold with an open mesh structure used for cranioplasty. A CAD/CAM titanium scaffold was removed due to late soft tissue complications 7.6 years after cranioplasty. The histological analyses involved the preparation of non-decalcified slices from the scaffold’s inner and outer sides as well as a light-microscopic evaluation, including the quantification of the bone that had formed over the years. Within the scaffold pores, vital connective tissue with both blood vessels and nerves was found. Exclusive bone formation only occurred at the edges of the implant, covering 0.21% of the skin-facing outer surface area. The inner scaffold surface, facing towards the brain, did not show any mineralization at all. Although conventional alloplastic materials for cranioplasty reduce surgery time and provide good esthetic results while mechanically protecting the underlying structures, a lack of adequate stimuli could explain the limited bone formation found. CAD/CAM porous titanium scaffolds alone insufficiently osseointegrate in such large bone defects of the skull. Future research should investigate alternative routes that enable long-term osteointegration in order to reduce complication rates after cranioplasty. Opportunities could be found in mechano-biologically optimized scaffolds, material modifications, surface coatings, or other routes to sustain bone formation.
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Favourable long-term recovery after decompressive craniectomy: the Northern Finland experience with a predominantly adolescent patient cohort. Childs Nerv Syst 2022; 38:1763-1772. [PMID: 35739289 PMCID: PMC9463249 DOI: 10.1007/s00381-022-05568-7] [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: 04/25/2021] [Accepted: 05/20/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Decompressive craniectomy (DC) is an effective treatment of intracranial hypertension. Correspondingly, the procedure is increasingly utilised worldwide. The number of patients rendered vegetative following surgery has been a concern-a matter especially important in children, due to long anticipated lifetime. Here, we report the long-term outcomes of all paediatric DC patients from an 11-year period in a tertiary-level centre that geographically serves half of Finland. METHODS We identified all patients younger than 18 years who underwent DC in the Oulu University Hospital between the years 2009 and 2019. Outcomes and clinicoradiological variables were extracted from the patient records. RESULTS Mean yearly prevalence of brain injury requiring DC was 1.34/100 000 children-twenty-four patients underwent DC during the study period and 21 (88%) survived. The median age of the patients was 16.0 years, and the median preoperative GCS was 5.0 (IQR 5.0). Fifteen patients (63%) had made a good recovery (Extended Glasgow Outcome Scale ≥ 7). Of the surviving patients, two (9.5%) had not returned to school. After traumatic brain injury (n = 20), the Rotterdam CT score (mean 3.0, range 1 to 5) was not associated with mortality, poor recovery or inability to continue school (p = 0.13, p = 0.41, p = 0.43, respectively). Absent basal cisterns were associated with mortality (p = 0.005), but not with poor recovery if the patient survived DC (p = 0.81). Hydrocephalus was associated with poor recovery and inability to continue school (p = 0.01 and p = 0.03, respectively). CONCLUSION Most of our patients made a favourable recovery and were able to continue school. No late mortality was observed. Thus, even in clinically and radiologically severely brain-injured children, decompressive craniectomy appears to yield favourable outcomes.
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Arai N, Abe H, Nishitani H, Kanemaru S, Yasunaga M, Yamamoto S, Seki S, Metani H, Hiraoka T, Hanayama K. Characteristics of Patients with Trephine Syndrome: A Retrospective Study. Prog Rehabil Med 2022; 7:20220008. [PMID: 35280326 PMCID: PMC8858714 DOI: 10.2490/prm.20220008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/24/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives: This study retrospectively investigated the prevalence and clinical features of trephine syndrome, which is a late complication of craniectom, in patients who underwent craniectomy decompression. Methods: Trephine syndrome was defined as an increase of ≥2 points in the functional independent measure (FIM) score at 7 days after cranioplasty compared with that 3 days before cranioplasty. Patients who underwent craniectomy at Kawasaki Medical School Hospital between January 1, 2010, and March 15, 2020, were included in the study. Results: During the observation period, 102 patients underwent craniectomy decompression; 71 of them later underwent cranioplasty. In total, 12 and 59 patients were assigned to the trephine and non-trephine syndrome groups, respectively. The patients in the trephine syndrome group were significantly younger than those in the non-trephine syndrome group (P<0.05). The mean durations±standard deviations (in days) from craniectomy decompression to cranioplasty were 57.1±38.9 and 83.6±69.3 for the trephine and non-trephine syndrome groups, respectively (P<0.05). Improvements in the FIM motor scores were greater than the improvements in the cognitive scores for all but one case (P<0.05). The frequency with which patients experienced exacerbation (worsened consciousness and sudden anisocoria) after hospitalization was significantly higher in the trephine syndrome group than in the non-trephine syndrome group (P<0.05). Conclusions: Performing cranioplasty as early as possible in young patients may lead to functional improvement. In the trephine syndrome group, the improvement in motor FIM score was greater than that of the cognitive score. Moreover, post-hospitalization exacerbation was more frequent in the trephine syndrome group.
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Affiliation(s)
- Nobuyuki Arai
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hiromasa Abe
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Haruhiko Nishitani
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Shimon Kanemaru
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Masaru Yasunaga
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Sayako Yamamoto
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Sousuke Seki
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hiromichi Metani
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takashi Hiraoka
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Kozo Hanayama
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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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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Spake CSL, Beqiri D, Rao V, Crozier JW, Svokos KA, Woo AS. Subgaleal drains may be associated with decreased infection following autologous cranioplasty: a retrospective analysis. Br J Neurosurg 2021:1-7. [PMID: 34751075 DOI: 10.1080/02688697.2021.1995588] [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: 05/21/2021] [Revised: 08/04/2021] [Accepted: 10/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Autologous bone is often the first choice in cranioplasty following a decompressive craniectomy. However, infection is a common complication, with reported rates up to 25%. While the incidence and management of infection are well documented, the risk factors associated with infection remain less clear. The current study aims to identify predictors of infection risk following autologous cranioplasty. METHODS A retrospective analysis was conducted on patients who underwent decompressive craniectomy and cranioplasty using cryopreserved autologous bone flaps between 2010 and 2020. Patient demographics and factors related to both surgeries and infection rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in the development of infection. RESULTS In our cohort, 126 patients underwent autologous cranioplasty. A total of 10 patients (7.9%) developed an infection following reconstruction, with half resulting in implant failure. We did not identify any significant risk factors for infection. Regression analysis identified placement of subgaleal drain following cranioplasty as a protective factor against the development of infection (OR: 0.16, p = 0.007). On average, drains remained in for 3 days, with no difference between the length of drains for those with infection vs. those without (p = 0.757). CONCLUSIONS The current study demonstrates an infection rate of 7.9% in patients who receive an autologous cranioplasty following decompressive craniectomy, which is consistent with previous data. Half (4%) of patients who experienced an infection ultimately required removal of the implant. While it is common practice for neurosurgeons to use drains to prevent hematomas and fluid collections, we found that subgaleal drain placement following cranioplasty was associated with decreased infection, thus demonstrating another benefit of a commonly used tool.
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Affiliation(s)
- Carole S L Spake
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Dardan Beqiri
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Vinay Rao
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Joseph W Crozier
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Konstantina A Svokos
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Albert S Woo
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Rufus P, Moorthy RK, Joseph M, Rajshekhar V. Post Traumatic Hydrocephalus: Incidence, Pathophysiology and Outcomes. Neurol India 2021; 69:S420-S428. [PMID: 35102998 DOI: 10.4103/0028-3886.332264] [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] [Indexed: 11/04/2022]
Abstract
Background Post-traumatic hydrocephalus (PTH) is a sequel of traumatic brain injury (TBI) that is seen more often in patients undergoing decompressive craniectomy (DC). It is associated with prolonged hospital stay and unfavorable outcomes. Objective To study the incidence and risk factors for development of PTH in patients undergoing DC in our institution and to review the literature on PTH with respect to incidence, risk factors, pathophysiology, and outcomes of management. Methods Data from 95 patients (among 220 patients who underwent DC for TBI and fulfilled the inclusion criteria) over a 5-year period at Christian Medical College, Vellore were collected and analyzed to study the incidence and possible risk factors for development of PTH. A review of the literature on PTH was performed by searching PUBMED resources. Results Thirty (31.6%) out of 95 patients developed post-traumatic ventriculomegaly, of whom seven (7.3%) developed symptomatic PTH, necessitating placement of ventriculoperitoneal shunt (VPS). No risk factor for development of PTH could be identified. The reported incidence of PTH in the literature is from 0.07% to 29%, with patients undergoing DC having a higher incidence. Younger age, subarachnoid hemorrhage, severity of TBI, presence of subdural hygroma, and delayed cranioplasty after DC are the main risk factors reported in the literature. Conclusions PTH occurs in a significant proportion of patients with TBI and can lead to unfavorable outcomes. PTH has to be distinguished from asymptomatic ventriculomegaly as early as possible so that a CSF diversion procedure can be planned early during development of PTH.
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Affiliation(s)
- Phelix Rufus
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ranjith K Moorthy
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vedantam Rajshekhar
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
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Marini CP, McNelis J, Petrone P. Multimodality Monitoring and Goal-Directed Therapy for the Treatment of Patients with Severe Traumatic Brain Injury: A Review for the General and Trauma Surgeon. Curr Probl Surg 2021; 59:101070. [DOI: 10.1016/j.cpsurg.2021.101070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
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Marini CP, McNelis J, Petrone P. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Clinical Study of Cranioplasty Combined With Ipsilateral Ventriculoperitoneal Shunt in the Treatment of Skull Defects With Hydrocephalus. J Craniofac Surg 2021; 33:289-293. [PMID: 34608006 DOI: 10.1097/scs.0000000000008227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To explore the clinical effect and safety of cranioplasty combined with ipsilateral ventriculoperitoneal shunts in the treatment of skull defects with hydrocephalus. METHODS The clinical data of 78 patients with skull defects with hydrocephalus were analyzed retrospectively. All patients were treated with cranioplasty and ventriculoperitoneal shunts in 1 stage, including 35 cases of cranioplasty combined with ipsilateral ventriculoperitoneal shunts (ipsilateral operation group) and 43 cases of contralateral operations (contralateral operation group). RESULTS The incision length (28.97 ± 4.55 cm), operation time (139.00 ± 42.27 minutes), and intraoperative hemorrhage (174.57 ± 79.35 mL) in the ipsilateral operation group were significantly better than those in the contralateral operation group (respectively they were 37.15 ± 5.83 cm, 214.07 ± 34.35 minutes, and 257.21 ± 72.02 mL), and the difference was statistically significant (t = 6.786, 8.656, and 4.815, all P < 0.05). The degree of postoperative hydrocephalus was significantly improved in both groups, but there was no statistically significant difference in the degree of hydrocephalus between the 2 groups (P > 0.05). Among the postoperative complications, there was no statistically significant difference in infection, epilepsy, subdural effusion, titanium plate effusion, or excessive cerebrospinal fluid drainage between the 2 groups (P > 0.05), but the incidence of intracranial hemorrhage in the ipsilateral operation group (2.86%) was significantly lower than that in the contralateral operation group (20.93%, χ2 = 4.138, P = 0.042). The postoperative Glasgow Coma Scale scores of the 2 groups were improved compared with those before the operation (P < 0.05), and there was no statistically significant difference in the postoperative Glasgow Coma Scale scores (P > 0.05). At 6 months after surgery, there was no statistically significant difference in Glasgow Outcome Scale effectiveness between the 2 groups (χ2 = 0.005, P = 0.944). CONCLUSIONS Cranioplasty combined with ipsilateral ventriculoperitoneal shunt has the same therapeutic effect as a contralateral operation, but it has the advantage of a short operation time, less intraoperative trauma, less bleeding, and less risk of intracranial hemorrhage, which is suitable for clinical applications.
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Sam JE, Kandasamy R, Wong ASH, Ghani ARI, Ang SY, Idris Z, Abdullah JM. Vacuum Drains versus Passive Drains versus No Drains in Decompressive Craniectomies-A Randomized Controlled Trial on Subgaleal Drain Complication Rates (VADER Trial). World Neurosurg 2021; 156:e381-e391. [PMID: 34563715 DOI: 10.1016/j.wneu.2021.09.074] [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: 07/11/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Subgaleal drains are generally deemed necessary for cranial surgeries including decompressive craniectomies (DCs) to avoid excessive postoperative subgaleal hematoma (SGH) formation. Many surgeries have moved away from routine prophylactic drainage but the role of subgaleal drainage in cranial surgeries has not been addressed. METHODS This was a randomized controlled trial at 2 centers. A total of 78 patients requiring DC were randomized in a 1:1:1 ratio into 3 groups: vacuum drains (VD), passive drains (PD), and no drains (ND). Complications studied were need for surgical revision, SGH amount, new remote hematomas, postcraniectomy hydrocephalus (PCH), functional outcomes, and mortality. RESULTS Only 1 VD patient required surgical revision to evacuate SGH. There was no difference in SGH thickness and volume among the 3 drain types (P = 0.171 and P = 0.320, respectively). Rate of new remote hematoma and PCH was not significantly different (P = 0.647 and P = 0.083, respectively), but the ND group did not have any patient with PCH. In the subgroup analysis of 49 patients with traumatic brain injury, the SGH amount of the PD and ND group was significantly higher than that of the VD group. However, these higher amounts did not translate as a significant risk factor for poor functional outcome or mortality. VD may have better functional outcome and mortality. CONCLUSIONS In terms of complication rates, VD, PD, and ND may be used safely in DC. A higher amount of SGH was not associated with poorer outcomes. Further studies are needed to clarify the advantage of VD regarding functional outcome and mortality, and if ND reduces PCH rates.
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Affiliation(s)
- Jo Ee Sam
- Department of Neurosciences, School of Medical Sciences, Jalan Hospital USM, Universiti Sains Malaysia Health Campus, Kota Bharu, Kelantan, Malaysia; Department of Neurosurgery, Hospital Umum Sarawak, Jalan Hospital, Sarawak, Malaysia.
| | - Regunath Kandasamy
- Department of Neurosciences, School of Medical Sciences, Jalan Hospital USM, Universiti Sains Malaysia Health Campus, Kota Bharu, Kelantan, Malaysia
| | - Albert Sii Hieng Wong
- Department of Neurosurgery, Hospital Umum Sarawak, Jalan Hospital, Sarawak, Malaysia
| | - Abdul Rahman Izaini Ghani
- Department of Neurosciences, School of Medical Sciences, Jalan Hospital USM, Universiti Sains Malaysia Health Campus, Kota Bharu, Kelantan, Malaysia
| | - Song Yee Ang
- Department of Neurosciences, School of Medical Sciences, Jalan Hospital USM, Universiti Sains Malaysia Health Campus, Kota Bharu, Kelantan, Malaysia
| | - Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Jalan Hospital USM, Universiti Sains Malaysia Health Campus, Kota Bharu, Kelantan, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences & Brain Behaviour Cluster, Hospital Universiti Sains, Malaysia, Universiti Sains Malaysia, Health Campus, Kota Bharu, Kelantan, Malaysia
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Fayed A, Tarek A, Refaat MI, Abouzeid S, Salim SA, Zsom L, Fülöp T, Soliman KM, Elmallawany MA. Retrospective analysis of nontraumatic subdural hematoma incidence and outcomes in Egyptian patients with end-stage renal disease on hemodialysis. Ren Fail 2021; 43:1322-1328. [PMID: 34547969 PMCID: PMC8462880 DOI: 10.1080/0886022x.2021.1979038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background The incidence of subdural hematoma (SDH) in chronic maintenance hemodialysis (CMH) patients may change over time, along with the evolving characteristics of the underlying populations. Methods We conducted a retrospective, single-center study at Cairo University hospitals, assessing the incidence, associated risk factors, and outcomes of nontraumatic SDH in CMH patients between January 2006 and January 2019. Results Out of 1217 CMH patients, nontraumatic SDH was diagnosed in 41 (3.37%) during the study, increasing with the enrollees’ age but stable over the observation period and translating into an annual incidence rate of 28 per 1000 patients per year. SDH patients were likely to use central venous catheters, reported pruritis and history of bone fractures, and had higher phosphorus, parathyroid hormone, and alkaline phosphatase values (p < 0.001); however, there was no association with atrial fibrillation or use of anticoagulants. In the SDH cohort (n = 41), six patients did not need surgical intervention and 13 patients died before becoming surgically fit for intervention; mortality correlated with ischemic heart disease (p = 0.033) and the presence of atrial fibrillation or chronic anticoagulation with warfarin (p < 0.0001 for both), among others. Twenty-two patients received surgical operations and of these 2 died postoperatively; overall patient mortality was 12/41 (29.27%) at 30 days and 15/41 (36.59%) at 1 year. Conclusion Our study demonstrated a striking enrichment for underlying comorbidities in those patients developing SDH and a high risk of immediate mortality. The benefit of chronic anticoagulation therapy should be carefully weighed against the risk of CNS bleed in MHD patients.
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Affiliation(s)
- Ahmed Fayed
- Nephrology Unit, Internal Medicine Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Ayman Tarek
- Neurosurgery Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed I Refaat
- Neurosurgery Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Sameh Abouzeid
- Nephrology Department, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Sohail Abdul Salim
- Department of Medicine, Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lajos Zsom
- Fresenius Medical Care Hungary, Cegléd, Hungary
| | - Tibor Fülöp
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA.,Medical Services, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Karim M Soliman
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA.,Department of Surgery, Transplant Nephrology, Medical University of South Carolina, Charleston, SC, USA
| | - Mohamed A Elmallawany
- Neurosurgery Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
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