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Cristofori I, Cohen-Zimerman S, Krueger F, Jabbarinejad R, Delikishkina E, Gordon B, Beuriat PA, Grafman J. Studying the social mind: An updated summary of findings from the Vietnam Head Injury Study. Cortex 2024; 174:164-188. [PMID: 38552358 DOI: 10.1016/j.cortex.2024.03.002] [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: 05/31/2023] [Revised: 01/26/2024] [Accepted: 03/01/2024] [Indexed: 04/21/2024]
Abstract
Lesion mapping studies allow us to evaluate the potential causal contribution of specific brain areas to human cognition and complement other cognitive neuroscience methods, as several authors have recently pointed out. Here, we present an updated summary of the findings from the Vietnam Head Injury Study (VHIS) focusing on the studies conducted over the last decade, that examined the social mind and its intricate neural and cognitive underpinnings. The VHIS is a prospective, long-term follow-up study of Vietnam veterans with penetrating traumatic brain injury (pTBI) and healthy controls (HC). The scope of the work is to present the studies from the latest phases (3 and 4) of the VHIS, 70 studies since 2011, when the Raymont et al. paper was published (Raymont et al., 2011). These studies have contributed to our understanding of human social cognition, including political and religious beliefs, theory of mind, but also executive functions, intelligence, and personality. This work finally discusses the usefulness of lesion mapping as an approach to understanding the functions of the human brain from basic science and clinical perspectives.
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Affiliation(s)
- Irene Cristofori
- Institute of Cognitive Sciences Marc Jeannerod CNRS, UMR 5229, Bron, France; University of Lyon, Villeurbanne, France.
| | - Shira Cohen-Zimerman
- Cognitive Neuroscience Laboratory, Brain Injury Research, Shirley Ryan AbilityLab, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA.
| | - Frank Krueger
- School of Systems Biology, George Mason University, Manassas, VA, USA; Department of Psychology, George Mason University, Fairfax, VA, USA.
| | - Roxana Jabbarinejad
- Cognitive Neuroscience Laboratory, Brain Injury Research, Shirley Ryan AbilityLab, Chicago, IL, USA.
| | - Ekaterina Delikishkina
- Cognitive Neuroscience Laboratory, Brain Injury Research, Shirley Ryan AbilityLab, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA.
| | - Barry Gordon
- Cognitive Neurology/Neuropsychology Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Cognitive Science, Johns Hopkins University, Baltimore, MD USA.
| | - Pierre-Aurélien Beuriat
- Institute of Cognitive Sciences Marc Jeannerod CNRS, UMR 5229, Bron, France; University of Lyon, Villeurbanne, France; Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Bron, France.
| | - Jordan Grafman
- Cognitive Neuroscience Laboratory, Brain Injury Research, Shirley Ryan AbilityLab, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA; Departments of Neurology, Psychiatry, and Cognitive Neurology & Alzheimer's Disease, Feinberg School of Medicine, Chicago, IL, USA; Department of Psychology, Northwestern University, Chicago, IL, USA.
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Calame DJ, Riaz M. Pediatric craniocerebral firearm injuries: literature review, best practices in medical and surgical management, and case report. Childs Nerv Syst 2023; 39:2195-2199. [PMID: 37100970 DOI: 10.1007/s00381-023-05968-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/19/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Civilian craniocerebral firearm injuries are extremely lethal. Management includes aggressive resuscitation, early surgical intervention when indicated, and management of intracranial pressure. Patient neurological status and imaging features should be used to guide management and the degree of intervention. Pediatric craniocerebral firearm injuries have a higher survival rate, but are much rarer, especially in children under 15 years old. This paucity of data underscores the importance of reviewing pediatric craniocerebral firearm injuries to determine best practices in surgical and medical management. CASE PRESENTATION A 2-year-old female was admitted after suffering a gunshot wound to the left frontal lobe. Upon initial evaluation, the patient displayed agonal breathing and fixed pupils with a GCS score of 3. CT imaging showed a retained ballistic projectile in the right temporal-parietal region with bifrontal hemorrhages, subarachnoid blood, and a 5-mm midline shift. The injury was deemed nonsurvivable and non-operable; thus, treatment was primarily supportive. Upon removal of the endotracheal tube, the patient began breathing spontaneously and improved clinically to a GCS score of 10-12. On hospital day 8, she underwent cranial reconstruction with neurosurgery. Her neurological status continued to improve, and she was able to communicate and follow commands but retained notable left-sided hemiplegia with some left-sided movement. On hospital day 15, she was deemed safe for discharge to acute rehabilitation.
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Affiliation(s)
- D J Calame
- Medical Scientist Training Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Department of Physiology and Biophysics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - M Riaz
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
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Nyberger K, Strömmer L, Wahlgren CM. A systematic review of hemorrhage and vascular injuries in civilian public mass shootings. Scand J Trauma Resusc Emerg Med 2023; 31:30. [PMID: 37337265 DOI: 10.1186/s13049-023-01093-x] [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: 02/06/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Civilian public mass shootings (CPMSs) are a major public health issue and in recent years several events have occurred worldwide. The aim of this systematic review was to characterize injuries and mortality after CPMSs focusing on in-hospital management of hemorrhage and vascular injuries. METHOD A systematic review of all published literature was undertaken in Medline, Embase and Web of Science January 1st, 1968, to February 22nd, 2021, according to the PRISMA guidelines. Literature was eligible for inclusion if the CPMS included three or more people shot, injured or killed, had vascular injuries or hemorrhage. RESULTS The search identified 2884 studies; 34 were eligible for inclusion in the analysis. There were 2039 wounded in 45 CPMS events. The dominating anatomic injury location per event was the extremity followed by abdomen and chest. The median number of operations and operated patients per event was 22 (5-101) and 10.5 (4-138), respectively. A total of 899 deaths were reported with a median mortality rate of 36.1% per event (15.9-71.4%) Thirty-eight percent (13/34) of all studies reported on vascular injuries. Vascular injuries ranged from 8 to 29%; extremity vascular injury the most frequent. Specific vascular injuries included thoracic aorta 18% (42/232), carotid arteries 6% (14/232), and abdominal aorta 5% (12/232). Vascular injuries were involved in 8.3%-10% of all deaths. CONCLUSION This systematic review showed an overall high mortality after CPMS with injuries mainly located to the extremities, thorax and abdomen. About one quarter of deaths was related to hemorrhage involving central large vessel injuries. Further understanding of these injuries, and structured and uniform reporting of injuries and treatment protocols may help improve evaluation and management in the future. Level of Evidence Systematic review and meta-analysis, level III.
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Affiliation(s)
- Karolina Nyberger
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden.
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Lovisa Strömmer
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Bertani R, Koester SW, Perret C, Pilon B, Batista S, Brocco B, Barbosa M, Maria PS, Von Zuben D, Ferreira-Pinto PHC, Monteiro R. Decompressive Hemicraniectomies as a Damage Control Approach for Multilobar Firearm Projectile Injuries: A Single-Center Experience. World Neurosurg 2023; 169:e96-e101. [PMID: 36280049 DOI: 10.1016/j.wneu.2022.10.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND While firearms projectile injuries to the head carry a high rate of morbidity and mortality, current literature in clinical management remains controversial. Decompressive hemicraniectomy (DHC) has been previously described in the neurosurgical literature for traumatic brain injuries, with positive results in the reduction of mortality. Here we aim to assess DHC as a damage control approach for multilobar firearm injuries to the head and compare our results with what is present in the literature. METHODS A retrospective review of patients who sustained multilobar firearm injuries to the head admitted to our center from January 2009 to April 2021 was performed. Exclusion criteria were a Glasgow Coma Scale (GCS) score <5, and/or brain stem dysfunction that persisted despite stabilization and medical therapy for intracranial hypertension. RESULTS A total of 20 patients were analyzed, with an average GCS on admission of 8.35. The 60-day mortality rate for all 20 patients was 20% with a total of 4 deaths, 1 of which was due to pulmonary sepsis in the critical postoperative care unit. The mean hospital stay of surviving patients was 22 days. CONCLUSIONS DHC should be considered as a damage control strategy for young patients with multilobar firearm injuries and GCS >5, having yielded favorable results in this study when compared to current literature.
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Affiliation(s)
- Raphael Bertani
- Department of Neurosurgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil.
| | - Stefan W Koester
- Department of Neurosurgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Caio Perret
- Department of Neurosurgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil; Department of Neuroscience, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Barbara Pilon
- Department of Neurosurgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil; Department of Neuroscience, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sávio Batista
- Department of Neuroscience, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Breno Brocco
- Department of Neuroscience, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maurício Barbosa
- Department of Neuroscience, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paulo Santa Maria
- Department of Neurosurgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Daniela Von Zuben
- Department of Neurosurgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Pedro Henrique Costa Ferreira-Pinto
- Department of Surgical Specialties, Neurosurgery Teaching and Assistance Unit, Pedro Ernesto University Hospital, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Ruy Monteiro
- Department of Neurosurgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
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A comparison of clinical characteristics, radiographic findings, and outcomes of bihemispheric versus unihemispheric gunshot wounds to the head. Am J Emerg Med 2022; 60:78-82. [DOI: 10.1016/j.ajem.2022.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/14/2022] [Accepted: 07/16/2022] [Indexed: 11/18/2022] Open
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Lu VM, Kreuger E, Cordeiro JG, Niazi TN, Jagid JR, McCrea HJ. Clinical complications of surviving gunshot wounds to the head in children and adolescents: the Miami experience. Childs Nerv Syst 2022; 38:1735-1742. [PMID: 35606660 DOI: 10.1007/s00381-022-05558-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/10/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Gunshot wounds (GSWs) to the head in the pediatric population are both rare and devastating, with the clinical course of pediatric survivors poorly understood. Correspondingly, the aim of this study was to summarize the clinical complications clinicians can expect of survivors of GSW to the head in children and adolescents in hospital and after discharge. METHODS A retrospective review of our Level 1 trauma center database between 2011 and 2021 was performed. Clinical data was extracted for those patients aged ≤ 18 years old who survived initial hospitalization with at least one documented follow-up. Categorical data were then compared using Chi-squared test. RESULTS A total of 19 pediatric survivors of GSW to the head satisfied all selection criteria with an average age was 15.3 years. The majority of cases were isolated head injuries (63%), with an average Glasgow Coma Score (GCS) of 11.9. Bullet trajectory was intraparenchymal in 11 (58%) cases and extraparenchymal in 8 (42%) cases, with 15 (79%) patients treated by surgical intervention. A total of 13 (68%) patients experienced a complication during their hospitalization, with the most common being sympathetic hypertension and endocrinologic salt wasting, each occurring in 5 (26%) patients. With respect to complication categories, the intraparenchymal patients experienced statistically more complications than extraparenchymal patients that were infectious (54% vs 0%, P = 0.01) and sympathetic (45% vs 0%, P = 0.03) in nature. However, with respect to overall neurologic (P = 0.24), endocrinologic (P = 0.24), and traumatic (P = 0.24) complications, their incidences were statistically comparable. All patients were successfully discharged on average post-injury day 22 with an average GCS of 14.0. Mean follow-up for the cohort was 42.6 months, with an average GCS of 14.3. A total of 6 (32%) patients experienced a complication relatable to their initial GSW injury after discharge. The most common individual complication was new-onset seizures in 3 (16%) patients. CONCLUSIONS Survivors of pediatric GSW to the head can experience multi-systemic complications during both initial hospitalization and afterwards, and bullet trajectory involving the parenchyma may be associated with specific complications more than others. Dedicated inpatient management and outpatient follow-up involving surveillance for complications across all systems, not just neurological, are recommended to ensure patients receive the best care possible.
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Affiliation(s)
- Victor M Lu
- Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL, USA.
| | - Evan Kreuger
- Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL, USA
| | - Joacir G Cordeiro
- Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL, USA
| | - Toba N Niazi
- Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL, USA.,Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL, USA
| | - Jonathan R Jagid
- Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL, USA
| | - Heather J McCrea
- Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL, USA.,Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL, USA
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Yue JK, Chang D, Han KJ, Wang AS, Oh T, Sun PP. Management of migrating intracranial bullet fragments in a 13-year-old female after firearm brain injury: technical and surgical nuances. Brain Inj 2022; 36:432-439. [PMID: 35099341 DOI: 10.1080/02699052.2022.2034185] [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: 11/02/2022]
Abstract
INTRODUCTION We present the challenges and nuances of management in a rare case of multiple migrating intracranial fragments after pediatric gunshot wound to the head (GSWH). CASE PRESENTATION A 13-year-old girl suffered left parietal GSWH, with new neurologic decline 3 days after initial debridement. Serial imaging showed the largest intracranial fragments had migrated into the left trigone, and descended further with head of bed (HOB) elevation. HOB was iteratively decreased, with concurrent intracranial pressure monitoring. After extubation, with an alert and stable neurologic exam, HOB was decreased to -15 degrees, allowing gravity-assisted migration of the fragments to an anatomically favorable position within the left occipital horn. The patient underwent occipital craniotomy for fragment retrieval on hospital day 27. Two large and >20 smaller fragments were retrieved using neuronavigation and intraoperative ultrasound. Forensics showed these to be .45 caliber handgun bullet fragments. The patient recovered well after 2-months of intensive inpatient rehabilitation. DISCUSSION During new neurologic decline after GSWH, bullet migration must be considered and serial cranial imaging is requisite. Surgical retrieval of deep fragments requires judicious planning to minimize further injury. Tightly controlled HOB adjustments with gravity assistance for repositioning of fragments may have utility in optimizing anatomic favorability prior to surgery.
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Affiliation(s)
- John K Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Diana Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kasey J Han
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Albert S Wang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Taemin Oh
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Peter P Sun
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Mudekereza PS, Murhula GB, Kachungunu C, Mudekereza A, Cikomola F, Mubenga LEM, Balungwe PB, Budema PM, Molima C, Mugabo EN, Lekuya HM. Factors associated with hospital outcomes of patients with penetrating craniocerebral injuries in armed conflict areas of the Democratic Republic of the Congo: a retrospective series. BMC Emerg Med 2021; 21:109. [PMID: 34600474 PMCID: PMC8487558 DOI: 10.1186/s12873-021-00504-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 09/21/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Penetrating craniocerebral injuries (PCCI) are types of open head injuries caused by sharp objects or missiles, resulting in communication between the cranial cavity and the external environment. This condition is deemed to be more prevalent in armed conflict regions where both civilians and military are frequently assaulted on the head, but paradoxically their hospital outcomes are under-reported. We aimed to identify factors associated with poor hospital outcomes of patients with PCCI. METHODS This was a retrospective series of patients admitted at the Regional Hospital of Bukavu, DRC, from 2010 to 2020. We retrieved medical records of patients with PCCI operated in the surgical departments. A multivariate logistic regression model was performed to find associations between patients' admission clinico-radiological parameters and hospital outcomes. Poor outcome was defined as a Glasgow Outcomes Score below 4. RESULTS The prevalence of PCCI was 9.1% (91/858 cases) among admitted TBI patients. More than one-third (36.2%) of patients were admitted with GCS < 13, and 40.6% of them were unstable hemodynamic. Hemiplegia was found in 23.1% on admission. Eight patients had an intracerebral hemorrhage. Among the 69 operated patients, complications, mainly infectious, occurred in half (50.7%) of patients. Poor hospital outcomes were observed in 30.4% and associated with an admission GCS < 13, hemodynamic instability, intracerebral hemorrhage, and hemiplegia (p < 0.05). CONCLUSION The hospital poor outcomes are observed when patients present with hemodynamic instability, an admission GCS < 13, intracerebral hemorrhage, and hemiplegia. There is a need for optimizing the initial care of patients with PCCI in armed conflict regions.
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Affiliation(s)
- Paterne Safari Mudekereza
- Faculté de Médecine, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
- Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
- Société Congolaise de Neurochirurgie (SCNC), Kinshasa, Democratic Republic of the Congo
| | | | - Charles Kachungunu
- Société Congolaise de Neurochirurgie (SCNC), Kinshasa, Democratic Republic of the Congo
| | - Amani Mudekereza
- Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Fabrice Cikomola
- Faculté de Médecine, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
- Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Leon-Emmanuel Mukengeshai Mubenga
- Faculté de Médecine, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
- Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Patrick Birindwa Balungwe
- Faculté de Médecine, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
- Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Paul Munguakonkwa Budema
- Faculté de Médecine, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
- Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Christian Molima
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Erick Namegabe Mugabo
- Hôpital Provincial Général de Référence de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Hervé Monka Lekuya
- Société Congolaise de Neurochirurgie (SCNC), Kinshasa, Democratic Republic of the Congo
- Department of Surgery, CHS, Makerere University, P.O. Box 7072, Kampala, Uganda
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Garg A, Mandal A, Aggarwal I, Galhotra A, Das S, Marwah S. Transcranial lateral perforating gunshot injury through skull base presenting without residual damage: A fortunate survivor. Chin J Traumatol 2021; 24:183-186. [PMID: 33750675 PMCID: PMC8173582 DOI: 10.1016/j.cjtee.2021.02.006] [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: 05/19/2020] [Revised: 11/10/2020] [Accepted: 12/21/2020] [Indexed: 02/04/2023] Open
Abstract
We reported a case of a 32 years old male presenting with a perforating gunshot injury in craniocerebral region 3 h after the assault. The bullet entered above the right zygomatic arch, travelling through the coronal plane, and exited from the left zygomatic arch. The patient was fully conscious at presentation and developed facial nerve palsy during his hospital stay. Non-contrast CT scan of the head revealed fractures of the right orbit, bilateral maxilla, bilateral pterygoid plates, ethmoid air cells, vomer and left zygoma, and without any cerebral damage. He was treated conservatively and the facial palsy was resolved. The patient survived without any complications. Such case has not been described in the available literature till date.
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Sellier A, Beucler N, Joubert C, Desse N, Dagain A. Letter to the Editor. Ballistic trajectory in civilian penetrating brain injury. J Neurosurg 2021; 135:664. [PMID: 33545671 DOI: 10.3171/2020.11.jns204043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Qi H, Li K. Civilian gunshot wounds to the head: a case report, clinical management, and literature review. Chin Neurosurg J 2021; 7:12. [PMID: 33531086 PMCID: PMC7856761 DOI: 10.1186/s41016-020-00227-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Civilian gunshot wounds to the head refer to brain injury caused by projectiles such as gun projectiles and various fragments generated by explosives in a power launch or explosion. Gunshot wounds to the head are the deadliest of all gun injuries. According to literature statistics, the survival rate of patients with gunshot wounds to the head is only 9%. Due to the strict management of various types of firearms, they rarely occur, so the injury mechanism, injury and trauma analysis, clinical management, and surgical standards are almost entirely based on military experience, and there are few related reports, especially of the head, in which an individual suffered a fatal blow more than once in a short time. We report a case with a return to almost complete recovery despite the patient suffering two gunshot injuries to the head in a short period of time. CASE PRESENTATIONS We present a case of a 53-year-old man who suffered two gunshot injuries to the head under unknown circumstances. On initial presentation, the patient had a Glasgow Coma Scale score of 6, was unable to communicate, and had loss of consciousness. The first bullet penetrated the right frontal area and finally reached the right occipital lobe. When the patient reflexively shielded his head with his hand, the second bullet passed through the patient's right palm bone, entered the right frontotemporal area, and came to rest deep in the lateral sulcus. The patient had a cerebral hernia when he was admitted to the hospital and immediately entered the operating room for rescue after a computed tomography scan. After two foreign body removals and skull repair, the patient recovered completely. CONCLUSIONS Gunshot wounds to the head have a high mortality rate and usually require aggressive management. Evaluation of most gunshot injuries requires extremely fast imaging examination upon arrival at the hospital, followed by proactive treatment against infection, seizure, and increased intracranial pressure. Surgical intervention is usually necessary, and its key points include the timing, method, and scope of the operation.
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Affiliation(s)
- Haoyi Qi
- Qinghai University, No. 251 Ningda Road, Xining, 810016 Qinghai Province China
| | - Kunzheng Li
- The Affiliated Hospital of Qinghai University, No. 29 Tongren Road, Xining, 810000 Qinghai Province China
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Traumatic Cerebrovascular Injuries Associated with Gunshot Wounds to the Head: A Single-Institution Ten-Year Experience. World Neurosurg 2020; 146:e1031-e1044. [PMID: 33227526 DOI: 10.1016/j.wneu.2020.11.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few studies have also attempted to define CVI risk factors and their role in patient outcomes. We aimed to describe 10 years of CVI from GSWH and characterize these injury patterns. METHODS Single-institution data from 2009 to 2019 were queried to identify patients presenting with dural-penetrating GSWH. Patient records were reviewed for GSWH characteristics, CVI patterns, management, and follow-up. RESULTS Overall, 63 of 297 patients with GSWH underwent computed tomography angiography (CTA) with 44.4% showing CVI. The middle cerebral artery (22.2%), dural venous sinuses (15.9%), and internal carotid artery (14.3%) were most frequently injured. Arterial occlusion was the most prominent injury type (22.2%) followed by sinus thrombosis (15.9%). One fifth of patients underwent delayed repeat CTA, with 20.1% showing new/previously unrecognized CVI. Bihemispheric bullet tracts were associated with CVI occurrence (P = 0.001) and mortality (P = 0.034). Dissection injuries (P = 0.013), injuries to the vertebrobasilar system (P = 0.036), or the presence of ≥2 concurrent CVIs (P = 0.024) were associated with increased risk of mortality. Of patients with CVI on initial CTA, 30% died within the first 24 hours. CONCLUSIONS CVI was found in 44.4% of patients who underwent CTA. Dissection and vertebrobasilar injuries are associated with the highest mortality. CTA should be considered in any potentially survivable GSWH. Longitudinal study with consistent CTA use is necessary to determine the true prevalence of CVI and optimize the use of imaging modalities.
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Wu Y, Chen T, Yuan M, Mzimbiri JM, Liu Z, Chen Y, Luo X, Chen F, Liu J. Orbitocranial Penetrating Injury With Multiple Vessel Invasion in an Infant: A Case Report and Literature Review. Front Neurol 2020; 11:591431. [PMID: 33281731 PMCID: PMC7689382 DOI: 10.3389/fneur.2020.591431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/19/2020] [Indexed: 01/17/2023] Open
Abstract
Orbitocranial penetrating injury (OPI) with multiple vascular invasions is a rare occurrence. To our knowledge, experience with its clinical treatment is rather limited, especially for infants. This case report describes an infant who fell from a 0.5 m high bed and landed on a toy with a keen-edged plastic rod. The fractured end of the rod was noted at the medial aspect of the left eyelid, and she was experiencing impaired consciousness. Computed tomography showed that the foreign body penetrated the cavernous sinus with internal carotid artery involvement, and compressed the transverse sinus through the cerebellum. Emergency surgery was performed with temporal occlusion of the left common carotid artery. The rod was removed from the orbital side, and bleeding from cavernous sinus region was effectively controlled under direct inspection via a sub-temporal approach. The patient was successfully treated and recovered consciousness after 17 days. This is the first report of successful management of OPI combined with multiple vascular injury in an infant. Herein, we highlight the anatomical imaging features of the injuries and also the individualized strategy concerning vascular invasion.
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Affiliation(s)
- Yun Wu
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Tiange Chen
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Meng Yuan
- Center for Experimental Medicine, The Third Xiangya Hospital of Central South University, Changsha, China
| | | | - Ziyuan Liu
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Yilei Chen
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Xiangying Luo
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Fenghua Chen
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Jinfang Liu
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
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14
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Kim LH, Quon JL, Cage TA, Lee MB, Pham L, Singh H. Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: A decision-tree algorithm based on a single trauma center. J Clin Neurosci 2020; 75:71-79. [PMID: 32241644 DOI: 10.1016/j.jocn.2020.03.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/20/2020] [Indexed: 11/30/2022]
Abstract
Gunshot wounds (GSW) are one of the most lethal forms of head trauma. The lack of clear guidelines for civilian GSW complicates surgical management. We aimed to develop a decision-tree algorithm for mortality prediction and report long-term outcomes on survivors based on 15-year data from our level 1 trauma center. We retrospectively reviewed 96 consecutive patients who presented with cerebral GSWs between 2003 and 2018. Clinical information from our trauma database, EMR, and relevant imaging scans was reviewed. A decision-tree model was constructed based on variables showing significant differences between survivors and non-survivors. After excluding patients who died at arrival, 54 patients with radiologically confirmed intracranial injury were included. Compared to survivors (51.9%), non-survivors (48.1%) were significantly more likely to have perforating (entry and exit wound), as opposed to penetrating (entry wound only), injuries. Bi-hemispheric and posterior fossa involvement, cerebral herniation, and intraventricular hemorrhage were more commonly present in non-survivors. Based on the decision-tree, Glasgow Coma Scale (GCS) > 8 and penetrating, uni-hemispheric injury predicted survival. Among patients with GCS ≤ 8 and normal pupillary response, lack of 1) posterior fossa involvement, 2) cerebral herniation, 3) bi-hemispheric injury, and 4) intraventricular hemorrhage, were associated with survival. Favorable long-term outcomes (mean follow-up 34.4 months) were possible for survivors who required neurosurgery and stable patients who were conservatively managed. We applied clinical and radiological characteristics that predicted survival to construct a decision-tree to facilitate surgical decision-making for GSW. Further validation of the algorithm in a large patient setting is recommended.
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Affiliation(s)
- Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Jennifer L Quon
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Tene A Cage
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Marco B Lee
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Lan Pham
- Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA.
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15
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Marut D, Shammassian B, McKenzie C, Adamski J, Traeger J. Evaluation of prophylactic antibiotics in penetrating brain injuries at an academic level 1 trauma center. Clin Neurol Neurosurg 2020; 193:105777. [PMID: 32197146 DOI: 10.1016/j.clineuro.2020.105777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Infections from penetrating brain injuries (PBI) lead to higher morbidity and mortality rates. The results of this research will be evaluated to develop institutional guideline for antibiotic prophylaxis in this patient population. The objective was to characterize the prophylactic antibiotic usage for patients presenting with PBI. PATIENTS AND METHODS This retrospective chart review included patients with a PBI identified through the institution's trauma center registry between December 2015 and July 2018. The primary outcome was the proportion of patients that received prophylactic antibiotics. Secondary outcomes included antibiotic administration timing, selection and duration of antibiotic regimens, infection rates and patient outcomes. RESULTS The study population included 33 patients, with 82 % males and an average age of 32 years. The most common mechanism of injury was a gunshot wound (94 %). Of the 33 patients, 24 (73 %) received at least one dose of prophylactic antibiotics. The median time to antibiotic administration was 52.8 min (IQR, 18-120), while the median duration of prophylaxis was 24 h (IQR, 7-84). The most common antibiotic regimen was a single cefazolin dose, with the next most common regimen included scheduled ceftriaxone and metronidazole. Overall, there were no documented central nervous system or skin and soft tissue infections during the initial admission, while 4 patients (12 %) were treated for pneumonia. Survivors (67 %) had a median hospital length of stay of 5.8 days. CONCLUSION The median duration of prophylaxis was shorter than the current data suggesting antibiotics for 5 days; however, there were no documented central nervous system infections, which is less than previously reported in the literature.
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Affiliation(s)
- Danielle Marut
- Department of Pharmacy, Cleveland Clinic Avon Hospital, Avon, OH, USA.
| | - Berje Shammassian
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christina McKenzie
- Department of Pharmacy, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - John Adamski
- Department of Trauma Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jessica Traeger
- Department of Pharmacy, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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16
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Kerr N, de Rivero Vaccari JP, Dietrich WD, Keane RW. Neural-respiratory inflammasome axis in traumatic brain injury. Exp Neurol 2019; 323:113080. [PMID: 31626746 DOI: 10.1016/j.expneurol.2019.113080] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/11/2019] [Accepted: 10/04/2019] [Indexed: 12/26/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality. Approximately 20-25% of TBI subjects develop Acute Lung Injury (ALI), but the pathomechanisms of TBI-induced ALI remain poorly defined. Currently, mechanical ventilation is the only therapeutic intervention for TBI-induced lung injury. Our recent studies have shown that the inflammasome plays an important role in the systemic inflammatory response leading to lung injury-post TBI. Here, we outline the role of the extracellular vesicle (EV)-mediated inflammasome signaling in the etiology of TBI-induced ALI. Furthermore, we evaluate the efficacy of a low molecular weight heparin (Enoxaparin, a blocker of EV uptake) and a monoclonal antibody against apoptosis speck-like staining protein containing a caspase recruitment domain (anti-ASC) as therapeutics for TBI-induced lung injury. We demonstate that activation of an EV-mediated Neural-Respiratory Inflammasome Axis plays an essential role in TBI-induced lung injury and disruption of this axis has therapeutic potential as a treatment strategy.
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Affiliation(s)
- Nadine Kerr
- Department of Neurological Surgery, University of Miami Miller School of Medicine, United States of America; Miami Project to Cure Paralysis, United States of America
| | - Juan Pablo de Rivero Vaccari
- Department of Neurological Surgery, University of Miami Miller School of Medicine, United States of America; Miami Project to Cure Paralysis, United States of America
| | - W Dalton Dietrich
- Department of Neurological Surgery, University of Miami Miller School of Medicine, United States of America; Miami Project to Cure Paralysis, United States of America
| | - Robert W Keane
- Department of Neurological Surgery, University of Miami Miller School of Medicine, United States of America; Miami Project to Cure Paralysis, United States of America; Department of Physiology and Biophysics, University of Miami Miller School fo Medicine, 1600 NW10th Avenue, Miami, FL 33136, United States of America.
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17
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Hutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T, Bajamal AH, Barthélemy EJ, Devi BI, Bhat D, Bulters D, Chesnut R, Citerio G, Cooper DJ, Czosnyka M, Edem I, El-Ghandour NMF, Figaji A, Fountas KN, Gallagher C, Hawryluk GWJ, Iaccarino C, Joseph M, Khan T, Laeke T, Levchenko O, Liu B, Liu W, Maas A, Manley GT, Manson P, Mazzeo AT, Menon DK, Michael DB, Muehlschlegel S, Okonkwo DO, Park KB, Rosenfeld JV, Rosseau G, Rubiano AM, Shabani HK, Stocchetti N, Timmons SD, Timofeev I, Uff C, Ullman JS, Valadka A, Waran V, Wells A, Wilson MH, Servadei F. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement. Acta Neurochir (Wien) 2019; 161:1261-1274. [PMID: 31134383 PMCID: PMC6581926 DOI: 10.1007/s00701-019-03936-y] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. METHODS The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. RESULTS The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. CONCLUSIONS In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
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Affiliation(s)
- Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Tamara Tajsic
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Amos Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Abenezer Tirsit Aklilu
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Tedy Apriawan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Abdul Hafid Bajamal
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - B Indira Devi
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya Bhat
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Diederik Bulters
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Randall Chesnut
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Idara Edem
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa and University of Thessaly, Larissa, Greece
| | - Clare Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Corrado Iaccarino
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Mathew Joseph
- Department of Neurosurgery, Christian Medical College, Vellore, India
| | - Tariq Khan
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Tsegazeab Laeke
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Oleg Levchenko
- Department of Neurosurgery, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Paul Manson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Anna T Mazzeo
- Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Daniel B Michael
- Oakland University William Beaumont School of Medicine and Michigan Head & Spine Institute, Auburn Hills, MI, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesia/Critical Care & Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Gail Rosseau
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shelly D Timmons
- Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Chris Uff
- Department of Neurosurgery, The Royal London Hospital, London, UK
- Queen Mary University of London, London, UK
| | - Jamie S Ullman
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Vicknes Waran
- Neurosurgery Division, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adam Wells
- Department of Neurosurgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Mark H Wilson
- Imperial Neurotrauma Centre, Department of Surgery and Cancer, Imperial College, London, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
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18
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Kassi AAY, Mahavadi AK, Clavijo A, Caliz D, Lee SW, Ahmed AI, Yokobori S, Hu Z, Spurlock MS, Wasserman JM, Rivera KN, Nodal S, Powell HR, Di L, Torres R, Leung LY, Rubiano AM, Bullock RM, Gajavelli S. Enduring Neuroprotective Effect of Subacute Neural Stem Cell Transplantation After Penetrating TBI. Front Neurol 2019; 9:1097. [PMID: 30719019 PMCID: PMC6348935 DOI: 10.3389/fneur.2018.01097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/03/2018] [Indexed: 12/13/2022] Open
Abstract
Traumatic brain injury (TBI) is the largest cause of death and disability of persons under 45 years old, worldwide. Independent of the distribution, outcomes such as disability are associated with huge societal costs. The heterogeneity of TBI and its complicated biological response have helped clarify the limitations of current pharmacological approaches to TBI management. Five decades of effort have made some strides in reducing TBI mortality but little progress has been made to mitigate TBI-induced disability. Lessons learned from the failure of numerous randomized clinical trials and the inability to scale up results from single center clinical trials with neuroprotective agents led to the formation of organizations such as the Neurological Emergencies Treatment Trials (NETT) Network, and international collaborative comparative effectiveness research (CER) to re-orient TBI clinical research. With initiatives such as TRACK-TBI, generating rich and comprehensive human datasets with demographic, clinical, genomic, proteomic, imaging, and detailed outcome data across multiple time points has become the focus of the field in the United States (US). In addition, government institutions such as the US Department of Defense are investing in groups such as Operation Brain Trauma Therapy (OBTT), a multicenter, pre-clinical drug-screening consortium to address the barriers in translation. The consensus from such efforts including “The Lancet Neurology Commission” and current literature is that unmitigated cell death processes, incomplete debris clearance, aberrant neurotoxic immune, and glia cell response induce progressive tissue loss and spatiotemporal magnification of primary TBI. Our analysis suggests that the focus of neuroprotection research needs to shift from protecting dying and injured neurons at acute time points to modulating the aberrant glial response in sub-acute and chronic time points. One unexpected agent with neuroprotective properties that shows promise is transplantation of neural stem cells. In this review we present (i) a short survey of TBI epidemiology and summary of current care, (ii) findings of past neuroprotective clinical trials and possible reasons for failure based upon insights from human and preclinical TBI pathophysiology studies, including our group's inflammation-centered approach, (iii) the unmet need of TBI and unproven treatments and lastly, (iv) present evidence to support the rationale for sub-acute neural stem cell therapy to mediate enduring neuroprotection.
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Affiliation(s)
- Anelia A Y Kassi
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Anil K Mahavadi
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Angelica Clavijo
- Neurosurgery Service, INUB-MEDITECH Research Group, El Bosque University, Bogotá, CO, United States
| | - Daniela Caliz
- Neurosurgery Service, INUB-MEDITECH Research Group, El Bosque University, Bogotá, CO, United States
| | - Stephanie W Lee
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Aminul I Ahmed
- Wessex Neurological Centre, University Hospitals Southampton, Southampton, United Kingdom
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Zhen Hu
- Department of Neurosurgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Markus S Spurlock
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Joseph M Wasserman
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Karla N Rivera
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Samuel Nodal
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Henry R Powell
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Long Di
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Rolando Torres
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Lai Yee Leung
- Branch of Brain Trauma Neuroprotection and Neurorestoration, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Andres Mariano Rubiano
- Neurosurgery Service, INUB-MEDITECH Research Group, El Bosque University, Bogotá, CO, United States
| | - Ross M Bullock
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Shyam Gajavelli
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
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19
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Maragkos GA, Papavassiliou E, Stippler M, Filippidis AS. Civilian Gunshot Wounds to the Head: Prognostic Factors Affecting Mortality: Meta-Analysis of 1774 Patients. J Neurotrauma 2018; 35:2605-2614. [DOI: 10.1089/neu.2018.5682] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Georgios A. Maragkos
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Efstathios Papavassiliou
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aristotelis S. Filippidis
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery, Boston Medical Center, Boston, Massachusetts
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20
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DeMario VM, Sikorski RA, Efron DT, Serbanescu MA, Buchanan RM, Wang EJ, Visagie M, Gehrie EA, Manukyan MC, Noll K, Ken Lee KH, Ness PM, Frank SM. Blood utilization and mortality in victims of gun violence. Transfusion 2018; 58:2326-2334. [PMID: 30209804 DOI: 10.1111/trf.14925] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Blood transfusion can be lifesaving for patients with hemorrhage; however, transfusion requirements for victims of gun violence are poorly understood. STUDY DESIGN AND METHODS In an urban, Level 1 trauma center, 23,422 trauma patients were analyzed in a retrospective cohort study. Patients with gunshot wounds (GSWs) (n = 2,672; 11.4% of trauma patients) were compared to those with non-GSW traumatic injuries from 2005 to 2017, to assess blood utilization. RESULTS The GSW cohort was approximately five times more likely to require transfusion (538 of 2672 [20.1%] vs. 798 of 20,750 [3.9%]; p < 0.0001), and the number of blood component units transfused per patient was approximately 10 times greater (3.3 ± 13.5 vs. 0.31 ± 3.8 units/patient; p < 0.0001), compared to the non-GSW cohort. The risk-adjusted likelihood of requiring high-dose transfusion was greater in the GSW cohort (odds ratio, 2.38; 95% confidence interval, 1.14-5.80), and requirements were increased for all four blood components (red blood cells, platelets, plasma, and cryoprecipitate). Patients with GSWs had approximately 14 times greater overall mortality (653 of 2672 [24.4%] vs. 352 of 20,750 [1.7%]; p < 0.0001]. Compared to non-GSW penetrating injuries (e.g., stab wounds), those with GSWs had approximately four times higher transfusion requirements (3.3 ± 13.5 vs. 0.80 ± 3.8 units/patient; p < 0.0001), and approximately eight times greater overall mortality (653 of 2672 [24.4%] vs. 28 of 956 [2.9%]; p < 0.0001). CONCLUSIONS Compared to other traumatic injuries, GSW injuries are associated with substantially greater blood utilization and mortality. Trauma centers treating GSW injuries should have ready access to all blood components and ability to implement massive transfusions.
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Affiliation(s)
- Vincent M DeMario
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Robert A Sikorski
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - David T Efron
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mara A Serbanescu
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Rica M Buchanan
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eric J Wang
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mereze Visagie
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Eric A Gehrie
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Pathology (Transfusion Medicine), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Mariuxi C Manukyan
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kathy Noll
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - K H Ken Lee
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Paul M Ness
- Department of Pathology (Transfusion Medicine), Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Steven M Frank
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
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21
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Deng H, Yue JK, Winkler EA, Dhall SS, Manley GT, Tarapore PE. Adult Firearm-Related Traumatic Brain Injury in United States Trauma Centers. J Neurotrauma 2018; 36:322-337. [PMID: 29855212 DOI: 10.1089/neu.2017.5591] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Civilian firearm injury is an important public health concern in the United States. Gunshot wounds to the head (GSWH) remain in need of update and systematic characterization. We identify predictors of prolonged hospital length of stay (HLOS), intensive care unit length of stay (ICU LOS), medical complications, mortality, and discharge disposition from a population-based sample using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB), years 2003-2012. Statistical significance was assessed at α < 0.001 to correct for multiple comparisons. In total, 8148 adult GSWH patients were included extrapolating to 32,439 national incidents. Age was 36.6 ± 16.4 years and 64.4% were severe traumatic brain injury (TBI; Glasgow Coma Scale [GCS] score 3-8). Assault (49.2%), handgun (50.3%), and residential injury (43.2%) were of highest incidence. HLOS and ICU LOS were 7.7 ± 14.2 and 5.7 ± 13.4 days, respectively. Overall mortality was 54.6%; suicide/self-injury was associated with the highest mortality rate (71.6%). GCS, Injury Severity Score, and hypotension were significant predictors for outcomes overall. Medicare/Medicaid patients had longer HLOS compared to private/commercial insured (mean increase, 4.4 days; 95% confidence interval [2.6-6.3]). Compared to the Midwest, the South had longer HLOS (mean increase, 3.7 days; [2.0-5.4]) and higher odds of complications (odds ratio [OR], 1.7 [1.4-2.0]); the West had lower odds of complications (OR, 0.6; [0.5-0.7]). Versus handgun, shotgun (OR, 0.3; [0.2-0.4]) and hunting rifle (OR, 0.5; [0.4-0.8]) resulted in lower mortality. Patients with government/other insurance had higher odds of discharging home compared to private/commercially insured (OR, 1.7; [1.3-2.3]). In comparison to level I trauma centers, level II trauma centers had lower odds of discharge to home (OR, 0.7; [0.5-0.8]). Our results support hypotension, injury severity, injury intent, firearm type, and U.S. geographical location as important prognostic variables in firearm-related TBI. Improved understanding of civilian GSWH is critical to promoting increased awareness of firearm injuries as a public health concern and reducing its debilitating injury burden to patients, families, and healthcare systems.
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Affiliation(s)
- Hansen Deng
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - John K Yue
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Ethan A Winkler
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Sanjay S Dhall
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Geoffrey T Manley
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Phiroz E Tarapore
- 1 Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,2 Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
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22
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Darwazeh R, Darwazeh M, Sbeih I, Yan Y, Wang J, Sun X. Traumatic Brain Injury Caused by Missile Wounds in the North of Palestine: A Single Institution's Experience with 520 Consecutive Civilian Patients. World Neurosurg 2018; 116:e329-e339. [DOI: 10.1016/j.wneu.2018.04.202] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 12/15/2022]
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23
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Aydoseli A, Unal TC, Aras Y, Sabanci PA, Altunrende E, Izgi N. Endoscopic Removal of a Bullet That Migrated to the Third Ventricle Causing Hydrocephalus. World Neurosurg 2017. [PMID: 28645596 DOI: 10.1016/j.wneu.2017.06.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hydrocephalus caused by an intraventricular bullet is a rare event. We report a case of endoscopic removal of an intraventricular bullet. CASE DESCRIPTION A 66-year-old man was admitted with a gunshot wound to the head after a suicide attempt. The bullet migrated from the frontal parenchyma to the third ventricle day 4 of admission. On day 21 of admission, the patient developed hydrocephalus with obstruction of the cerebral aqueduct. The bullet was accessed through an endoscopic third ventriculostomy and removed using an endoscope. CONCLUSIONS Hydrocephalus may develop in patients with intraventricular foreign objects. When such objects must be removed, the endoscopic approach is a safe, efficient, and minimally invasive procedure. To our knowledge, this is the first case in the literature of foreign object removal from the ventricle via a transcortical endoscopic approach.
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Affiliation(s)
- Aydın Aydoseli
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Tugrul Cem Unal
- Department of Neurosurgery, Tunceli State Hospital, Tunceli, Turkey.
| | - Yavuz Aras
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Pulat Akın Sabanci
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Emre Altunrende
- Department of Neurosurgery, Gaziosmanpasa Taksim Training and Research Hospital, Istanbul, Turkey
| | - Nail Izgi
- Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
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24
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Milton J, Awuor V. A Unique Presentation of an Intracranial Abscess Secondary to Retained Projectile after Debridement with Dural Closure. Cureus 2017; 9:e1328. [PMID: 28690961 PMCID: PMC5501717 DOI: 10.7759/cureus.1328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients with penetrating head trauma with retained projectiles develop intracranial abscesses as a common complication. The most common presentation is a suddenly worsening headache. The most common pathogen identified is staphylococcus. Outcomes are related to adherence of Matson’s tenets. This case study details the presentation of a 19-year-old patient that presented to the neurological surgery clinic without neurologic deficits. Further questioning revealed complaints of intermittent diffuse headaches with bilateral upper extremity shock-like sensation for two weeks. Eight weeks prior he had undergone right craniotomy, after a gunshot wound, for debridement and watertight dural closure. The patient denied symptoms of fever, chills, nausea, vomiting, diarrhea, or seizure. The patient presented with a noncontrast head computed tomography (CT) which revealed retained projectile fragments without clear evidence of abscess. On physical exam, the patient was without any neurological deficit. Laboratory investigation revealed normal white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and negative blood cultures. Head CT with contrast revealed a large intracerebral abscess adjacent to the thalamus. The patient was taken to the operating room for repeat craniotomy with resection of the abscess and removal of the intracranial projectile fragments. Post-operatively, the patient remained neurology intact. Intraoperative cultures were not significant for the growth of any bacteria. In eight weeks time, the patient returned to his employment and his baseline level of activity. This case underscores the importance of thorough assessment in patients with retained intracranial projectiles as well as the need to routine follow-up. The unique presentation of this patient prompted further investigation which elucidated a lesion which correlated to his symptoms although laboratory assessment was without abnormality.
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25
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Mei QY, Li Y, He C, Shan HW, Wang YK, Dong Y, Yu MK, Hou LJ. Combination of dura turning-over and decompressive craniectomy: a new pattern of surgery for cerebral infarction caused by craniocerebral gunshot injury. Mil Med Res 2017; 4:26. [PMID: 28828175 PMCID: PMC5561627 DOI: 10.1186/s40779-017-0135-4] [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: 04/20/2017] [Accepted: 08/04/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Craniocerebral gunshot injury refers to a wound caused by a bullet passing through or lodged in brain tissue, resulting in the loss of function of a certain area or other fatal damage to the human brain. Craniocerebral gunshot injury is usually life-threatening and is very common in modern warfare, accounting for the majority of battle casualties. Most of the patients suffer from acute cerebral infarction caused by vascular injury. Lack of early and solid battlefield emergency medical interference adds to the risk of death among the wounded. CASE PRESENTATION We present a 24-year-old man who was shot with a shotgun from a distance of 15 m in an accidental injury. Forty-seven grapeshots were found on his body surface by physical examination. A computed tomography (CT) scan demonstrated large areas of low-density shadows in his right parietal lobe and right temporal lobe with the midline shifting to the left side 2 days later. Afterwards, the patient was transferred to our emergency medical center at Changzheng Hospital in Shanghai. Cranial computed tomography angiography (CTA) showed a high-density shadow in the initial part of the right middle cerebral artery. The branches after the initial part were obliterated. Prompt medical attention and decompressive craniotomy (DC) surgery contributed to the final recovery from cerebral infarction of this patient. CONCLUSION Bullets can penetrate or be lodged in the brain, causing intracranial hypertension. The bullets lodged in the brain can result in stenosis and embolism of a cerebral artery, causing acute cerebral infarction. Combining dura turning-over surgery with DC surgery can not only decrease intracranial pressure, which can increase the blood supply for hypertension-induced vessel stenosis, but also help vessels outside the dura mater grow into ischemic areas of the cerebral cortex. However, this new pattern of surgery needs further support from evidence-based medicine.
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Affiliation(s)
- Qi-Yong Mei
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
| | - Yao Li
- Department of Hepatic Surgery III, Eastern Hepatobiliary Surgical Hospital, Shanghai, 200438 China
| | - Chao He
- Department of Emergency, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai, 200003 China
| | - Hong-Wei Shan
- Department of Emergency, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai, 200003 China
| | - Yun-Kun Wang
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
| | - Yan Dong
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
| | - Ming-Kun Yu
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
| | - Li-Jun Hou
- Department of Neurosurgery, Shanghai Changzheng Hospital, the Second Military Medical University, Shanghai Neurosurgical Institute, Shanghai, 200003 China
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