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Klieverik VM, Robe PA, Muradin MS, Woerdeman PA. Cosmetic satisfaction and patient-reported outcome measures following cranioplasty after craniectomy - A prospective cohort study. BRAIN & SPINE 2023; 3:101767. [PMID: 37383454 PMCID: PMC10293317 DOI: 10.1016/j.bas.2023.101767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Abstract
Introduction Evaluating patient-reported outcomes (PROMs) helps optimize preoperative counseling and psychosocial care for patients who underwent cranioplasty. Research question This study aimed to evaluate cosmetic satisfaction, level of self-esteem, and fear of negative evaluation (FNE) of patients who underwent cranioplasty. Material and methods Patients who underwent cranioplasty from 1 January 2014 to 31 December 2020 at University Medical Center Utrecht and a control group consisting of our center' employees were invited to fill out the Craniofacial Surgery Outcomes Questionnaire (CSO-Q), consisting of an assessment of cosmetic satisfaction, the Rosenberg Self-Esteem Scale (RSES), and the FNE scale. To test for differences in results, chi-square tests and T-tests were performed. Logistic regression was used to study the effect of cranioplasty-related variables on cosmetic satisfaction. Results Cosmetic satisfaction was seen in 44/80 patients (55.0%) and 52/70 controls (74.3%) (p = 0.247). Thirteen patients (16.3%) and 8 controls (11.4%) had high self-esteem (p = 0.362), 51 patients (63.8%) and 59 controls (84.3%) had normal self-esteem (p = 0.114), and 7 patients (8.8%) and 3 controls (4.3%) had low self-esteem (p = 0.337). Forty-nine patients (61.3%) and 39 controls (55.7%) had low FNE (p = 0.012), 8 patients (10.0%) and 18 controls (25.7%) had average FNE (p = 0.095), and 6 patients (7.5%) and 13 controls (18.6%) had high FNE (p = 0.215). Cosmetic satisfaction was associated with glass fiber-reinforced composite implants (OR 8.20, p-value = 0.04). Discussion and conclusion This study prospectively evaluated PROMs following cranioplasty, for which we found favorable results.
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Affiliation(s)
- Vita M. Klieverik
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pierre A. Robe
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marvick S.M. Muradin
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter A. Woerdeman
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Hakiki B, Liuzzi P, Pansini G, Pancani S, Romoli A, Draghi F, Orlandini S, Mannini A, Della Puppa A, Macchi C, Cecchi F. Impact of decompressive craniectomy on functional outcome of severe acquired brain injuries patients, at discharge from intensive inpatient rehabilitation. Disabil Rehabil 2022; 44:8375-8381. [PMID: 34928755 DOI: 10.1080/09638288.2021.2015461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE Decompressive craniectomy (DC) is a life-saving procedure conducted to treat refractory intracranial hypertension. Although DC reduces mortality of severe Acquired Brain Injury (sABI) survivors, it has been associated with severe long-term disability. This observational study compares functional outcomes at discharge from an Intensive Rehabilitative Unit (IRU) between sABI patients with and without DC. MATERIAL AND METHODS sABI patients undergoing DC before entering the Don Gnocchi Foundation IRU were compared with a group of sABI patients who did not undergo DC (No-DC group), after matching it by age, sex, aetiology, time post-onset, and clinical status. Inclusion criteria were: diagnosis of sABI, age 18+, time from the event <90 days. RESULTS A total of 87 (DC: 47) patients were included (median age: 60.5 [IQR = 17.47]). The two groups did not differ for admission clinical features except for the tracheostomy presence (more frequent in DC, p < 0.001). No significant differences were also found at discharge. DC group presented a significantly longer length-of-stay than No-DC group (p < 0.001) and a longer time to tracheostomy removal (p = 0.036). DC was not found to influence outcomes as consciousness improvement, tracheostomy removal, oral intake and functional independence. CONCLUSIONS sABI patients with DC improved after rehabilitation as much as No-DC patients did but they required a longer stay.Implications for RehabilitationDecompressive craniectomy (DC) is practiced during the acute phase after hemorrhagic, ischemic, traumatic severe brain injury as a life-saving procedure to treat refractory intracranial hypertensionDC has been associated with follow-up severe long-term disability, but no study yet addressed whether DC may affect intensive rehabilitation outcomes.Undergoing a DC is not a negative prognostic factor for achieving rehabilitation goals after a severe acquired brain injuryDC must be taken into account when customizing rehabilitation pathway especially because these patients required a longer time to reach the outcomes.
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Affiliation(s)
- Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,The BioRobotics Institute, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio 34, Pontedera (Pi), Italy
| | - Gastone Pansini
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Silvia Pancani
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Annamaria Romoli
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Simone Orlandini
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,The BioRobotics Institute, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio 34, Pontedera (Pi), Italy
| | - Alessandro Della Puppa
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,Department of Experimental and Clinical Medicine, Università di Firenze, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,Department of Experimental and Clinical Medicine, Università di Firenze, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
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3
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Zhao JL, Song J, Yuan Q, Bao YF, Sun YR, Li ZQ, Xi CH, Yao HJ, Wang MH, Wu G, Du ZY, Hu J, Yu J. Characteristics and therapeutic profile of TBI patients who underwent bilateral decompressive craniectomy: experience with 151 cases. Scand J Trauma Resusc Emerg Med 2022; 30:59. [PMCID: PMC9670501 DOI: 10.1186/s13049-022-01046-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: 05/29/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background Decompressive craniectomy (DC) and intracranial pressure (ICP) monitoring are common approaches to reduce the death rate of Traumatic brain injury (TBI) patients, but the outcomes of these patients are unfavorable, particularly those who receive bilateral DC. The authors discuss their experience using ICP and other potential methods to improve the outcomes of TBI patients who receive bilateral DC. Methods Data from TBI patients receiving bilateral DC from Jan. 2008 to Jan. 2022 were collected via a retrospective chart review. Included patients who received unplanned contralateral DC after initial surgery were identified as unplanned secondary surgery (USS) patients. Patients’ demographics and baseline medical status; pre-, intra-, and postoperative events; and follow-up visit outcome data were analyzed. Results A total of 151 TBI patients were included. Patients who underwent USS experienced more severe outcomes as assessed using the 3-month modified Rankin Scale score (P = 0.024). In bilateral DC TBI patients, USS were associated with worsen outcomes, moreover, ICP monitoring was able to lower their death rate and was associated with a lower USS incidence. In USS patients, ICP monitoring was not associated with improved outcomes but was able to lower their mortality rate (2/19, 10.5%, vs. 10/25, 40.0%; P = 0.042). Conclusion The avoidance of USS may be associated with improved outcomes of TBI patients who underwent bilateral DC. ICP monitoring was a potential approach to lower USS rate in TBI patients, but its specific benefits were uncertain. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01046-w.
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Affiliation(s)
- Jian-Lan Zhao
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Jie Song
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Qiang Yuan
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Yi-Feng Bao
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Yi-Rui Sun
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Zhi-Qi Li
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Cai-Hua Xi
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Hai-Jun Yao
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Mei-Hua Wang
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Gang Wu
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Zhuo-Ying Du
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Jin Hu
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China ,grid.8547.e0000 0001 0125 2443Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Jian Yu
- grid.8547.e0000 0001 0125 2443Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
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Gidda R, Bandyopadhyay S, Peter N, Lakhoo K. Decompressive Craniectomy for Pediatric Traumatic Brain Injury in Low-and-Middle Income and High Income Countries. World Neurosurg 2022; 166:251-260.e1. [PMID: 35872132 DOI: 10.1016/j.wneu.2022.07.073] [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: 03/06/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 12/15/2022]
Abstract
Traumatic brain injury is one of the leading causes of mortality and morbidity in children worldwide. In severe cases, high intracranial pressure is the most frequent cause of death. When first-line medical management fails, the neurosurgical procedure of decompressive craniectomy (DC) has been proposed for controlling intracranial pressure and improving the long-term outcomes for children with severe traumatic brain injury. However, the use of this procedure is controversial. The evidence from clinical trials shows some promise for the use of DC as an effective second-line treatment. However, it is limited by conflicting trial results, a lack of trials, and a high risk of bias. Furthermore, most research comes from retrospective observational studies and case series. This narrative review considers the strength of evidence for the use of DC in both a high income country and low-and-middle income country setting and examine how we can improve study design to better assess the efficacy of this procedure and increase the clinical translatability of results to centers worldwide. Specifically, we argue for a need for further studies with higher pediatric participant numbers, multicenter collaboration, and the use of a more consistent methodology to enable comparability of results among settings.
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Affiliation(s)
- Ryan Gidda
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom.
| | - Soham Bandyopadhyay
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Noel Peter
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Kokila Lakhoo
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
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Effects of Cranioplasty on Contralateral Subdural Effusion After Decompressive Craniectomy: A Literature Review. World Neurosurg 2022; 165:147-153. [PMID: 35779748 DOI: 10.1016/j.wneu.2022.06.117] [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: 01/19/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Contralateral subdural effusion(CSE) after decompressive craniectomy (CSEDC) is occasionally observed. Cranioplasty is routinely performed for reconstruction and has recently been associated with improving contralateral subdural effusion . OBJECTIVE To systematically review all available literature and evaluate the effectiveness of cranioplasty for CSE. METHODS A PubMed, Web of Science, and Google Scholar search was conducted for preferred reporting items following the guidelines of systematic review and meta-analysis, including studies reporting patients who underwent cranioplasty because of CSEDC. RESULTS The search yielded eight articles. A total of 56 patients ranging in age from 21 to 71 years, developed CSEDC. Of them, 32 patients underwent cranioplasty. Eighteen cases with symptomatic CSE underwent cranioplasty alone, two cases received Ommaya drainage later because of a a recurrence of CDC, and one case underwent a ventriculoperitoneal shunt because the CSE did not resolve completely and the ventricle was dilated again. The symptoms of 14 cases lessened without recurrence after simultaneous cranioplasty and drainage or a shunt. The total success rate(CSE disappeared without recurrence) was 90.6% for patients who underwent cranioplasty; however, the total incidence of hydrocephalus was 40.1%. CONCLUSIONS This review suggests that cranioplasty is effective for the treatment of CSEDC, particularly intractable cases, but early cranioplasty may be more effective. In addition, hydrocephalus is fairly common after cranioplasty and requires further treatment.
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Singla N, Latawa A. Paradoxical Brain Herniation after Cranioplasty: Secondary Sunken Flap Syndrome. J Neurosci Rural Pract 2022; 13:105-107. [PMID: 35110928 PMCID: PMC8803515 DOI: 10.1055/s-0041-1741565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
AbstractDecompressive craniectomy is a life-saving procedure done for innumerable etiologies. Though, not a technically demanding procedure, it has its own complications. Among many, sinking flap syndrome or syndrome of the trephined or paradoxical herniation of brain is frequently underestimated. It results from the pressure difference between the atmospheric pressure and the intracranial pressure causing the brain to shift inward at the craniectomy site. This can present with either nonspecific symptoms leading to delay in diagnosis or acute neurological deterioration, memory disturbances, weakness, confusion, lethargy, and sometimes death if not treated. Cranioplasty is a time validated procedure used to treat paradoxical brain herniation with good and early neurological recovery. We, here in, are going to describe a case report in which the paradoxical herniation occurred after cranioplasty which has not been described in literature.
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Affiliation(s)
- Navneet Singla
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research, Chandigarh, Chandigarh, India
| | - Archit Latawa
- Department of Neurosurgery, Postgraduate Institute of Medical Education & Research, Chandigarh, Chandigarh, India
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Clinical Value of Bilateral Balanced Frontotemporoparietal Decompressive Craniectomy in Severe Diffuse Traumatic Brain Injury. J Craniofac Surg 2021; 33:279-283. [PMID: 34967525 DOI: 10.1097/scs.0000000000008121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To explore the clinical value of bilateral balanced frontotemporoparietal decompressive craniectomy (bbDC) in severe diffuse traumatic brain injury by comparison to the unilateral frontotemporoparietal decompressive craniectomy (uDC). MATERIALS AND METHODS Twenty three patients with severe diffuse traumatic brain injury from April 2015 to December 2019 were selected, including 10 cases underwent bbDC (bilateral group) and 13 cases underwent uDC (unilateral group). Compared with the postsurgical intracranial pressure (ICP), cerebral perfusion pressure, cerebral blood flow volume, postsurgical imaging score, the occurrence of complications as well as the 6 month outcome (Glasgow Outcome Scale, GOS) of two groups. RESULTS 1. The postsurgical ICP was lower in the bbDC group than in the uDC group, while the postsurgical CCP and cerebral blood flow volume were higher in the bbDC group than in the uDC group. 2. Postsurgical imaging scores of the bbDC group were lower, indicating that the decompression effect of bbDC was more exhaustive than that of the uDC group. 3. The incidence of intraoperative acute cerebral bulging was lower in bbDC group than in uDC group. 4. The bbDC could effectively reduce the proportion of patients with the worst prognosis (dead+vegetative state). CONCLUSION For patients with severe, diffuse traumatic brain injury combined with bilateral or unilateral pupil dilation, bilateral balanced decompression craniotomy is an effective method, which should be performed as soon as possible. As compared to unilateral decompression, the decompression effect on the brainstem is more thorough; the incidence of acute cerebral bulging, postoperative incisional hernia, and postoperative cerebral infarction involving a large area are reduced. ICP can be better controlled, cerebral perfusion pressure and cerebral blood flow increases, improving the patient's survival rate, quality of life, and prognosis.
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Corallo F, Lo Buono V, Calabrò RS, De Cola MC. Can Cranioplasty Be Considered a Tool to Improve Cognitive Recovery Following Traumatic Brain Injury? A 5-Years Retrospective Study. J Clin Med 2021; 10:jcm10225437. [PMID: 34830718 PMCID: PMC8624554 DOI: 10.3390/jcm10225437] [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: 10/07/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 01/19/2023] Open
Abstract
Cranioplasty (CP) is a neurosurgical intervention of skull repairing following a decompressive craniectomy. Unfortunately, the impact of cranioplasty on cognitive and motor function is still controversial. Fifteen TBI subjects aged 26–54 years with CP after decompressive craniectomy were selected in this observational retrospective study. As per routine clinical practice, a neuropsychological evaluation carried out immediately before the cranioplasty (Pre CP) and one month after the cranioplasty (T0) was used to measure changes due to CP surgery. This assessment was performed each year for 5 years after discharge in order to investigate long-term cognitive changes (T1-T5). Before cranioplasty, about 53.3% of subjects presented a mild to severe cognitive impairment and about 40.0% a normal cognition. After CP, we found a significant improvement in all neuropsychological test scores. The more significant differences in cognitive recovery were detected after four years from CP. Notably, we found significant differences between T4 and T0-T1, as well as between T5 and T0-T1-T2 in all battery tests. This retrospective study further suggests the importance of CP in the complex management of patients with TBI showing how these patients might improve their cognitive function over a long period after the surgical procedure.
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Chua KSG, Krishnan RR, Yen JM, Plunkett TK, Soh YM, Lim CJ, Chia CM, Looi JC, Ng SG, Rao J. 3D-printed external cranial protection following decompressive craniectomy after brain injury: A pilot feasibility cohort study. PLoS One 2021; 16:e0258296. [PMID: 34710123 PMCID: PMC8553164 DOI: 10.1371/journal.pone.0258296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 09/20/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES 3D-printed (3DP) customized temporary cranial protection solutions following decompressive craniectomy (DC) are currently not widely practiced. A pilot trial of a 3DP customized head protection prototype device (HPPD) on 10 subjects was conducted during the subacute rehabilitation phase. MATERIALS AND METHODS Subjects > 30 days post-DC with stable cranial flaps and healed wounds were enrolled. HPPD were uniquely designed based on individuals' CT scan, where the base conformed to the surface of the individual's skin covering the cranial defect, and the lateral surface three-dimensionally mirrored, the contralateral healthy head. Each HPPD was fabricated using the fused deposition modeling method. These HPPD were then fitted on subjects using a progressive wearing schedule and monitored over 1, 2, 4, 6 and 8 follow-up (FU) weeks. Outcomes during FU included; reported wearing time/day (hours), subjective pain, discomfort, pruritus, dislodgment, cosmesis ratings; and observed wound changes. The primary outcome was safety and tolerability without pain or wound changes within 30 minutes of HPPD fitting. RESULTS In all, 10 enrolled subjects received 12 HPPDs [5/10 male, mean (SD) age 46 (14) years, mean (SD) duration post-DC 110 days (76)] and all subjects tolerated 30 minutes of initial HPPD fitting without wound changes. The mean (SD) HPPD mass was 61.2 g (SD 19.88). During 8 weeks of FU, no HPPD-related skin dehiscence was observed, while 20% (2/10) had transient skin imprints, and 80% (8/10) reported self-limiting pressure and pruritis. DISCUSSION Findings from this exploratory study demonstrated preliminary feasibility and safety for a customized 3DP HPPD for temporary post-DC head protection over 8 weeks of follow-up. Monitoring and regular rest breaks during HPPD wear were important to prevent skin complications. CONCLUSION This study suggests the potential for wider 3DP technology applications to provide cranial protection for this vulnerable population.
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Affiliation(s)
- Karen Sui Geok Chua
- Tan Tock Seng Rehabilitation Centre, Tan Tock Seng Hospital, Singapore, Singapore
- * E-mail:
| | - Rathi Ratha Krishnan
- Tan Tock Seng Rehabilitation Centre, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jia Min Yen
- Tan Tock Seng Rehabilitation Centre, Tan Tock Seng Hospital, Singapore, Singapore
| | - Tegan Kate Plunkett
- Tan Tock Seng Rehabilitation Centre, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yan Ming Soh
- Tan Tock Seng Rehabilitation Centre, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chien Joo Lim
- Clinical Research and Innovation Office, Tan Tock Seng Hospital, Singapore, Singapore
| | | | | | - Suan Gek Ng
- Department of Neurosurgery, National Neuroscience Institute, TTSH Campus, Singapore, Singapore
| | - Jai Rao
- Department of Neurosurgery, National Neuroscience Institute, TTSH Campus, Singapore, Singapore
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10
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A Clinical Study on Individualized Surgical Scheme of Hydrocephalus Complicated With Skull Defect. J Craniofac Surg 2021; 32:2435-2440. [PMID: 34705388 DOI: 10.1097/scs.0000000000007571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE This study intends to discuss the individualized selection of surgical scheme of hydrocephalus complicated with skull defect. METHODS A total of 141 patients with hydrocephalus complicated with skull defect in our hospital from January 2012 to December 2018 were the main subjects of this study. Among these 141 patients, 78 patients underwent shunt and skull repair surgery in our hospital. In the present study, according to the classification of bone window tension, and combined with factors that affect the operation, different surgical schemes were selected, namely, repair surgery in the first phase and shunt surgery in the second phase, or simultaneous surgery, or shunt surgery in the first phase and repair surgery in the second phase. RESULTS The results of the present study show that an individualized surgical scheme can allow for the operation of hydrocephalus complicated with skull defect, without increasing the risk of complications, such as shunt infection, epidural hematoma, etc. CONCLUSIONS The surgical scheme for hydrocephalus complicated with skull defect differs in clinic.
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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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Shah DB, Paudel P, Joshi S, Karki P, Sharma GR. Outcome of Decompressive Craniectomy for Traumatic Brain Injury: An Institutional-Based Analysis from Nepal. Asian J Neurosurg 2021; 16:288-293. [PMID: 34268153 PMCID: PMC8244698 DOI: 10.4103/ajns.ajns_392_20] [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: 08/10/2020] [Revised: 11/25/2020] [Accepted: 03/16/2021] [Indexed: 11/11/2022] Open
Abstract
Objective: Decompressive craniectomy (DC) is one of the commonly used treatment modalities for refractory intracranial hypertension after traumatic brain injury. The objective of this study is to assess the functional outcome following DC in closed traumatic brain injury based on Glasgow Outcome Scale (GOS). Materials and Methods: This is a retrospective study conducted at Nepal Mediciti Hospital, Nepal, from September 2017 to October 2019. Data of the patients who had undergone DC for closed traumatic brain injury were reviewed from medical record files. Patients who had DC for nontraumatic causes were excluded from the study. Functional outcome was assessed using GOS at 3 months of follow-up. Results: Of the 52 decompressive craniectomies, 46 were included in the study. The majority was male (71.7%). The mean age and the mean Glasgow Coma Scale (GCS) score at presentation were 41.87 (standard deviation [SD] ± 15.29) and 7.59 (SD ± 2.97), respectively. The most common mode of injury was road traffic accident (76.1%). 60.9% had GCS score ≤8 while 39.1% had >8 GCS on admission. 34.8% had both the pupils reactive while 58.7% were anisocoric. Majority had Marshall IV and above grade of injury (67.4%). Sixteen (34.8%) had inhospital mortality. Favorable outcome was seen in 39.1%. GCS score >8 at presentation (72.2%, P < 0.001), bilaterally intact pupillary reflexes (75%, P < 0.001), Marshall grade injury ≤3 on computed tomography scan (90%, P < 0.001), and age <50 years (50%, P = 0.039) were significantly associated with favorable outcome. Procedure-related complications were seen in 36.9%. Conclusion: Favorable outcome was seen in 39.1%. Age <50 years, higher GCS score at presentation (>8), intact pupillary reflexes, and lower Marshall grade injuries were associated with favorable outcome. We recommend a larger prospective study to assess the long-term functional outcome after DC using extended GOS.
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Affiliation(s)
| | - Prakash Paudel
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Sumit Joshi
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Prasanna Karki
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
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Zhang C, Wang Y, Chen J, Yang S, Wang Y. Controlled decompression alleviates early brain injury in rabbit intracranial hypertension model by regulating apoptosis/necroptosis. Acta Cir Bras 2021; 36:e360406. [PMID: 34076083 PMCID: PMC8184258 DOI: 10.1590/acb360406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 03/10/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose To evaluate the effects of controlled decompression and rapid decompression,
explore the potential mechanism, provide the theoretical basis for the
clinical application, and explore the new cell death method in intracranial
hypertension. Methods Acute intracranial hypertension was triggered in rabbits by epidural balloon
compression. New Zealand white rabbits were randomly put into the sham
group, the controlled decompression group, and the rapid decompression
group. Brain water content, etc., was used to evaluate early brain injury.
Western blotting and double immunofluorescence staining were used to detect
necroptosis and apoptosis. Results Brain edema, neurological dysfunction, and brain injury appeared after
traumatic brain injury (TBI). Compared with rapid decompression, brain water
content was significantly decreased, neurological scores were improved by
controlled decompression treatment. Terminal deoxynucleotidyl transferase
dUTP nick end labeling (TUNEL) staining and Nissl staining showed neuron
death decreased in the controlled decompression group. Compared with rapid
decompression, it was also found that apoptosis-related protein caspase-3/
tumor necrosis factor (TNF)-a was reduced markedly in the brain cortex and
serum, and the expression levels of necroptosis-related protein,
receptor-interacting protein 1 (RIP1)/receptor-interacting protein 1 (RIP3)
reduced significantly in the controlled decompression group. Conclusions Controlled decompression can effectively reduce neuronal damage and cerebral
edema after craniocerebral injury and, thus, protect the brain tissue by
alleviating necroptosis and apoptosis.
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Affiliation(s)
- Can Zhang
- Wuxi Medical College of Anhui Medical University, China
| | - Yue Wang
- Wuxi Medical College of Anhui Medical University, China
| | - Junhui Chen
- Wuxi Medical College of Anhui Medical University, China
| | - Shuo Yang
- Wuxi Medical College of Anhui Medical University, China
| | - Yuhai Wang
- Wuxi Medical College of Anhui Medical University, China
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14
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Invasive neuromonitoring and neurological intensive care unit management in life-threatening central nervous system infections. Curr Opin Neurol 2021; 34:447-455. [PMID: 33935217 DOI: 10.1097/wco.0000000000000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Patients with infectious diseases of the central nervous system (CNS) commonly require treatment in the intensive care unit (ICU). In a subset of patients with a life-threatening course, a more aggressive and invasive management is required. Treatment relies on the expertise of the intensivists as most recommendations are currently not based on a high level of evidence. RECENT FINDINGS Published data suggest that an invasive brain-focused management should be considered in life-threatening CNS infections. Brain resuscitation by adequate control of intracranial pressure (ICP) and optimization of cerebral perfusion, oxygen and glucose delivery supports the idea of personalized medicine. Recent advances in monitoring techniques help to guide clinicians to improve neurocritical care management in these patients with severe disease. Robust data on the long-term effect of decompressive craniectomy and targeted temperature management are lacking, however, these interventions can be life-saving in individual patients in the setting of a potentially fatal situation such as refractory elevated ICP. SUMMARY Advances in the neurocritical care management and progress in monitoring techniques in specialized neuro-ICUs may help to preserve brain function and prevent a deleterious cascade of secondary brain damage in life-threatening CNS infections.
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Decompressive Craniectomy Improves QTc Interval in Traumatic Brain Injury Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228653. [PMID: 33233364 PMCID: PMC7700327 DOI: 10.3390/ijerph17228653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 12/11/2022]
Abstract
Background: Traumatic brain injury (TBI) is commonly associated with cardiac dysfunction, which may be reflected by abnormal electrocardiograms (ECG) and/or contractility. TBI-related cardiac disorders depend on the type of cerebral injury, the region of brain damage and the severity of the intracranial hypertension. Decompressive craniectomy (DC) is commonly used to reduce intra-cranial hypertension (ICH). Although DC decreases ICH rapidly, its effect on ECG has not been systematically studied. The aim of this study was to analyze the changes in ECG in patients undergoing DC. Methods: Adult patients without previously known cardiac diseases treated for isolated TBI with DC were studied. ECG variables, such as: spatial QRS-T angle (spQRS-T), corrected QT interval (QTc), QRS and T axes (QRSax and Tax, respectively), STJ segment and the index of cardio-electrophysiological balance (iCEB) were analyzed before DC and at 12–24 h after DC. Changes in ECG were analyzed according to the occurrence of cardiac arrhythmias and 28-day mortality. Results: 48 patients (17 female and 31 male) aged 18–64 were studied. Intra-cranial pressure correlated with QTc before DC (p < 0.01, r = 0.49). DC reduced spQRS-T (p < 0.001) and QTc interval (p < 0.01), increased Tax (p < 0.01) and changed STJ in a majority of leads but did not affect QRSax and iCEB. The iCEB was relatively increased before DC in patients who eventually experienced cardiac arrhythmias after DC (p < 0.05). Higher post-DC iCEB was also noted in non-survivors (p < 0.05), although iCEB values were notably heart rate-dependent. Conclusions: ICP positively correlates with QTc interval in patients with isolated TBI, and DC for relief of ICH reduces QTc and spQRS-T. However, DC might also increase risk for life-threatening cardiac arrhythmias, especially in ICH patients with notably prolonged QTc before and increased iCEB after DC.
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16
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Jiang HS, Wang YZ. Super early cranial repair improves the prognosis of patients with craniocerebral injury. J Int Med Res 2020; 48:300060520959485. [PMID: 32996793 PMCID: PMC7536486 DOI: 10.1177/0300060520959485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective Craniocerebral injury has high disability and mortality rates. The timing of
cranioplasty has an important impact on patients’ prognosis. This study was
performed to compare the functional prognosis between super early repair and
conventional repair. Methods This observational study included 60 patients who underwent cranioplasty
after surgical treatment of severe craniocerebral trauma. The patients were
divided into two groups according to the time of cranial repair after the
surgical treatment of craniocerebral injury: the super early group and the
conventional repair group. Sex, age, Karnofsky performance status (KPS)
score, Zubrod performance status (ZPS) score, psychological function score,
quality of life score, and complications were recorded. Results The KPS score, ZPS score, psychological function score, and quality of life
score were significantly related to the intervention period. Each of these
scores had a clear correlation with the performance of super early
treatment. Conclusion Super early cranial repair does not increase the incidence of surgical
complications, and it can improve the postoperative KPS, ZPS, and quality of
life scores.
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Affiliation(s)
- Hong-Sheng Jiang
- Department of Fourth Neurosurgery, Cangzhou Central Hospital, Cangzhou, Hebei Province, P.R. China
| | - Yan-Zhou Wang
- Department of Fourth Neurosurgery, Cangzhou Central Hospital, Cangzhou, Hebei Province, P.R. China
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Kim JH, Ahn JH, Oh JK, Song JH, Park SW, Chang IB. Factors associated with the development and outcome of hydrocephalus after decompressive craniectomy for traumatic brain injury. Neurosurg Rev 2020; 44:471-478. [PMID: 31953782 DOI: 10.1007/s10143-019-01179-0] [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: 07/07/2019] [Revised: 07/29/2019] [Accepted: 09/04/2019] [Indexed: 11/28/2022]
Abstract
Posttraumatic hydrocephalus (PTH) is common in patients undergoing decompressive craniectomy (DC) for traumatic brain injury (TBI), but the incidence, mechanisms, and risk factors have not been fully elucidated. This study aimed to determine the incidence of and the factors associated with PTH. We retrospectively reviewed patients who underwent DC for TBI at our institute between January 2014 and December 2018. We identified and compared the demographic, clinical, and radiological data, and 12-month functional outcome (as assessed by the Glasgow Outcome Scale [GOS]) between patients who developed PTH and those who did not. Logistic regression analyses were performed to identify risk factors for PTH. Additionally, the influence of PTH on unfavorable functional outcome was analyzed. PTH developed in 18 (18.95%) of the 95 patients who survived at 1 month after DC. A multivariate analysis indicated that postoperative intraventricular hemorrhage (odds ratio [OR] 4.493, P = 0.020), postoperative subdural hygroma (OR 4.074, P = 0.021), and postoperative hypothermia treatment (OR 9.705, P = 0.010) were significantly associated with PTH. The 12-month functional outcome significantly differed between the patients who developed PTH and those who did not (P = 0.049). Patients who developed PTH had significantly poorer 12-month functional outcomes than those who did not (P = 0.049). Another multivariate analysis indicated that subdural hemorrhage (OR 6.814, P = 0.031) and the presence of at least one dilated pupil before DC (OR 8.202, P = 0.000) were significantly associated with unfavorable functional outcomes (GOS grades 1-3). Although the influence of PTH (OR 5.122, P = 0.056) was not statistically significant in the multivariate analysis, it had a great impact on unfavorable functional outcomes. PTH considerably affects functional outcomes at 12 months after DC for TBI. Furthermore, postoperative imaging findings such as intraventricular hemorrhage and subdural hygroma can predict the development of PTH; therefore, careful observation is required during the follow-up period.
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Affiliation(s)
- Ji Hee Kim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro, Dongan-gu, Anyang-si, 14068, Gyeonggi-do, Republic of Korea
| | - Jun Hyong Ahn
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro, Dongan-gu, Anyang-si, 14068, Gyeonggi-do, Republic of Korea
| | - Jae Keun Oh
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro, Dongan-gu, Anyang-si, 14068, Gyeonggi-do, Republic of Korea
| | - Joon Ho Song
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro, Dongan-gu, Anyang-si, 14068, Gyeonggi-do, Republic of Korea
| | - Seung Woo Park
- Department of Neurosurgery, Kangwon National University College of Medicine, Chuncheon, Republic of Korea
| | - In Bok Chang
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro, Dongan-gu, Anyang-si, 14068, Gyeonggi-do, Republic of Korea.
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18
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Ong C, Hutch M, Barra M, Kim A, Zafar S, Smirnakis S. Effects of Osmotic Therapy on Pupil Reactivity: Quantification Using Pupillometry in Critically Ill Neurologic Patients. Neurocrit Care 2020; 30:307-315. [PMID: 30298336 DOI: 10.1007/s12028-018-0620-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Osmotic therapy is a critical component of medical management for cerebral edema. While up to 90% of neurointensivists report using these treatments, few quantitative clinical measurements guide optimal timing, dose, or administration frequency. Its use is frequently triggered by a qualitative assessment of neurologic deterioration and/or pupil size, and anecdotally appears to improve pupil asymmetry suggestive of uncal herniation. However, subjective pupil assessment has poor reliability, making it difficult to detect or track subtle changes. We hypothesized that osmotic therapy reproducibly improves quantitative pupil metrics. METHODS We included patients at two centers who had recorded quantitative pupil measurements within 2 h before and after either 20% mannitol or 23.4% hypertonic saline in the neurosciences intensive care unit. The primary outcome was the Neurologic Pupil Index (NPi), a composite metric ranging from 0 to 5 in which > 3 is considered normal. Secondary outcomes included pupil size, percent change, constriction and dilation velocity, and latency. Results were analyzed with Wilcoxon signed-rank tests, Chi-square and multi-level linear regression to control for other edema-reducing interventions. RESULTS Out of 72 admissions (403 paired pupil observations), NPi significantly differed within 2 h of osmotic therapy when controlling for other commonly used interventions in our whole cohort (β = 0.08, p = 0.0168). The effect was most pronounced (β = 0.57) in patients with abnormal NPi prior to intervention (p = 0.0235). CONCLUSIONS Pupil reactivity significantly improves after osmotic therapy in a heterogenous critically ill population when controlling for various other interventions. Future work is necessary to determine dose-dependent effects and clinical utility.
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Affiliation(s)
- C Ong
- Boston University School of Medicine, Boston, USA.
- Brigham and Women's Hospital, Boston, USA.
- Harvard Medical School, Boston, USA.
| | - M Hutch
- Boston University School of Medicine, Boston, USA
| | - M Barra
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - A Kim
- Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - S Zafar
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - S Smirnakis
- Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
- Jamaica Plain VA Hospital, Boston, USA
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19
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Sharaf B, Asaad M, Banuelos J, Meaike J. Deformation of cranioplasty titanium mesh in a paediatric patient following head trauma. BMJ Case Rep 2019; 12:12/6/e230421. [PMID: 31189547 DOI: 10.1136/bcr-2019-230421] [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: 11/04/2022] Open
Abstract
Decompressive craniectomy is a life-saving procedure performed to treat intracranial hypertension caused by a variety of conditions. Subsequent cranioplasty reconstruction is needed for brain protection. Different alloplastic materials with different advantages and disadvantages are available for cranial reconstruction. We present the first case of a deformed titanium cranioplasty mesh in a paediatric patient following head trauma. Children who have undergone cranioplasty reconstruction should be counselled to wear a protective helmet when involved in contact sports or activities that may put their implant at risk of trauma.
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Affiliation(s)
- Basel Sharaf
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Malke Asaad
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joseph Banuelos
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jesse Meaike
- Department of Surgery, Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
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20
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Laskowitz DT, Bennett ER, Durham RJ, Volpi JJ, Wiese JR, Frankel M, Shpall E, Wilson JM, Troy J, Kurtzberg J. Allogeneic Umbilical Cord Blood Infusion for Adults with Ischemic Stroke: Clinical Outcomes from a Phase I Safety Study. Stem Cells Transl Med 2018; 7:521-529. [PMID: 29752869 PMCID: PMC6052613 DOI: 10.1002/sctm.18-0008] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/21/2018] [Indexed: 12/16/2022] Open
Abstract
Stroke is a major cause of death and long‐term disability, affecting one in six people worldwide. The only currently available approved pharmacological treatment for ischemic stroke is tissue plasminogen activator; however, relatively few patients are eligible for this therapy. We hypothesized that intravenous (IV) infusion of banked unrelated allogeneic umbilical cord blood (UCB) would improve functional outcomes in patients with ischemic stroke. To investigate this, we conducted a phase I open‐label trial to assess the safety and feasibility of a single IV infusion of non‐human leukocyte antigen (HLA) matched, ABO matched, unrelated allogeneic UCB into adult stroke patients. Ten participants with acute middle cerebral artery ischemic stroke were enrolled. UCB units were matched for blood group antigens and race but not HLA, and infused 3–9 days post‐stroke. The adverse event (AE) profile over a 12 month postinfusion period indicated that the treatment was well‐tolerated in these stroke patients, with no serious AEs directly related to the study product. Study participants were also assessed using neurological and functional evaluations, including the modified Rankin Score (mRS) and National Institute of Health Stroke Scale (NIHSS). At 3 months post‐treatment, all participants had improved by at least one grade in mRS (mean 2.8 ± 0.9) and by at least 4 points in NIHSS (mean 5.9 ± 1.4), relative to baseline. Together, these data suggest that a single i.v. dose of allogeneic non‐HLA matched human UCB cells is safe in adults with ischemic stroke, and support the conduct of a randomized, placebo‐controlled phase 2 study. stemcellstranslationalmedicine2018;7:521–529
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Affiliation(s)
| | | | - Rebecca J. Durham
- Robertson Clinical and Translational Cell Therapy Program, Duke Translational Research Institute/Duke UniversityDurhamNorth CarolinaUSA
| | - John J. Volpi
- Eddy Scurlock Stroke Center, Houston Methodist Neurological InstituteHoustonTexasUSA
| | - Jonathan R. Wiese
- Eddy Scurlock Stroke Center, Houston Methodist Neurological InstituteHoustonTexasUSA
| | - Michael Frankel
- Department of NeurologyEmory University School of MedicineAtlantaGeorgiaUSA
| | - Elizabeth Shpall
- MD Anderson Cancer Center, The University of TexasHoustonTexasUSA
| | - Jeffry M. Wilson
- MD Anderson Cancer Center, The University of TexasHoustonTexasUSA
| | - Jesse Troy
- Robertson Clinical and Translational Cell Therapy Program, Duke Translational Research Institute/Duke UniversityDurhamNorth CarolinaUSA
| | - Joanne Kurtzberg
- Robertson Clinical and Translational Cell Therapy Program, Duke Translational Research Institute/Duke UniversityDurhamNorth CarolinaUSA
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21
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Abbott NJ, Pizzo ME, Preston JE, Janigro D, Thorne RG. The role of brain barriers in fluid movement in the CNS: is there a 'glymphatic' system? Acta Neuropathol 2018; 135:387-407. [PMID: 29428972 DOI: 10.1007/s00401-018-1812-4] [Citation(s) in RCA: 341] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/16/2018] [Accepted: 01/24/2018] [Indexed: 12/15/2022]
Abstract
Brain fluids are rigidly regulated to provide stable environments for neuronal function, e.g., low K+, Ca2+, and protein to optimise signalling and minimise neurotoxicity. At the same time, neuronal and astroglial waste must be promptly removed. The interstitial fluid (ISF) of the brain tissue and the cerebrospinal fluid (CSF) bathing the CNS are integral to this homeostasis and the idea of a glia-lymph or 'glymphatic' system for waste clearance from brain has developed over the last 5 years. This links bulk (convective) flow of CSF into brain along the outside of penetrating arteries, glia-mediated convective transport of fluid and solutes through the brain extracellular space (ECS) involving the aquaporin-4 (AQP4) water channel, and finally delivery of fluid to venules for clearance along peri-venous spaces. However, recent evidence favours important amendments to the 'glymphatic' hypothesis, particularly concerning the role of glia and transfer of solutes within the ECS. This review discusses studies which question the role of AQP4 in ISF flow and the lack of evidence for its ability to transport solutes; summarizes attributes of brain ECS that strongly favour the diffusion of small and large molecules without ISF flow; discusses work on hydraulic conductivity and the nature of the extracellular matrix which may impede fluid movement; and reconsiders the roles of the perivascular space (PVS) in CSF-ISF exchange and drainage. We also consider the extent to which CSF-ISF exchange is possible and desirable, the impact of neuropathology on fluid drainage, and why using CSF as a proxy measure of brain components or drug delivery is problematic. We propose that new work and key historical studies both support the concept of a perivascular fluid system, whereby CSF enters the brain via PVS convective flow or dispersion along larger caliber arteries/arterioles, diffusion predominantly regulates CSF/ISF exchange at the level of the neurovascular unit associated with CNS microvessels, and, finally, a mixture of CSF/ISF/waste products is normally cleared along the PVS of venules/veins as well as other pathways; such a system may or may not constitute a true 'circulation', but, at the least, suggests a comprehensive re-evaluation of the previously proposed 'glymphatic' concepts in favour of a new system better taking into account basic cerebrovascular physiology and fluid transport considerations.
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Affiliation(s)
- N Joan Abbott
- Faculty of Life Sciences and Medicine, Institute of Pharmaceutical Science, King's College London, Franklin Wilkins Building 3.82, 150 Stamford St, London, SE1 9NH, UK.
| | - Michelle E Pizzo
- Division of Pharmaceutical Sciences, University of Wisconsin-Madison School of Pharmacy, Madison, WI, USA
- Clinical Neuroengineering Training Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Jane E Preston
- Faculty of Life Sciences and Medicine, Institute of Pharmaceutical Science, King's College London, Franklin Wilkins Building 3.82, 150 Stamford St, London, SE1 9NH, UK
| | - Damir Janigro
- Flocel Inc., Cleveland, OH, USA
- Department of Physiology, Case Western Reserve University, Cleveland, OH, USA
| | - Robert G Thorne
- Division of Pharmaceutical Sciences, University of Wisconsin-Madison School of Pharmacy, Madison, WI, USA.
- Clinical Neuroengineering Training Program, University of Wisconsin-Madison, Madison, WI, USA.
- Neuroscience Training Program, University of Wisconsin-Madison, Madison, WI, USA.
- Cellular and Molecular Pathology Graduate Training Program, University of Wisconsin-Madison, Madison, WI, USA.
- Institute for Clinical and Translational Research, University of Wisconsin-Madison, Madison, WI, USA.
- , 5113 Rennebohm Hall, 777 Highland Avenue, Madison, WI, 53705, USA.
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22
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Laghari AA, Bari ME, Waqas M, Ahmed SI, Nathani KR, Moazzam W. Outcome of Decompressive Craniectomy in Traumatic Closed Head Injury. Asian J Neurosurg 2018; 13:1053-1056. [PMID: 30459866 PMCID: PMC6208257 DOI: 10.4103/ajns.ajns_195_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: The aim of the current study was to observe functional outcomes of patients undergoing decompressive craniectomy (DC) for raised intracranial pressure (ICP) after blunt head injury and to assess possible predictive factors. Methodology: This study was a prospective cohort study which was conducted at Aga Khan University Hospital, Karachi over a period of 2 years (January 2015–December 2016). Adult patients, aged between 15 and 65 years of both genders undergoing DC during the study period were selected. Outcomes of DC were assessed at an interval of 3 months following injury using the Glasgow outcome score. The data were analyzed on IBM statistics SPSS version 21. Results: Seventy-two patients underwent DC for raised and refractory ICP. Glasgow Outcome Scale (GOS) at discharge, 1-month and 3-month follow-up were reported. GOS at 3-month follow-up showed 21 patients (29.2%) patients had a good recovery, moderate disability was reported in 16 patients (22.2%), and severe disability in 12 patients (16.7%), persistent vegetative state was seen in five patients (6.9%). Eighteen patients had in hospital mortality (25.0%). Tracheostomy and sphenoid fractures were found to be negative predictors of good functional outcome. Conclusions: DC is associated with an in hospital mortality of 25.0%. Favorable outcomes were seen in 51.4% patients. Tracheostomy and sphenoid fractures were negative predictors of good functional outcome. The results are comparable to international literature.
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Affiliation(s)
- Altaf Ali Laghari
- Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Muhammad Waqas
- Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Syed Ijlal Ahmed
- Department of neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
| | | | - Wardah Moazzam
- Department of neurosurgery, The Aga Khan University Hospital, Karachi, Pakistan
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