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Beucler N, Rambolarimanana T. How I do it: single-staged emergency neurosurgical management of frontal penetrating craniocerebral injury with depressed skull fracture. Acta Neurochir (Wien) 2024; 166:47. [PMID: 38286923 DOI: 10.1007/s00701-024-05941-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/25/2023] [Indexed: 01/31/2024]
Abstract
CONTEXT Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury. METHODS The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged. CONCLUSION Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery department, Sainte-Anne Military Teaching Hospital, 2 Boulevard Sainte-Anne, 83800, Toulon Cedex 9, France.
- Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, 75230, Paris Cedex 5, France.
| | - Tonifaniry Rambolarimanana
- Neurosurgery department, Sainte-Anne Military Teaching Hospital, 2 Boulevard Sainte-Anne, 83800, Toulon Cedex 9, France
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2
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Krueger EM, Benveniste RJ, Lu VM, Taylor RR, Kumar R, Cordeiro JG, Jagid JR. Simple wound closure compared with surgery for civilian cranial gunshot wounds. J Neurosurg 2023; 138:437-445. [PMID: 35901757 DOI: 10.3171/2022.5.jns22617] [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: 03/14/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE A carefully selected subset of civilian cranial gunshot wound (CGSW) patients may be treated with simple wound closure (SWC) as a proactive therapy, but the appropriate clinical scenario for using this strategy is unknown. The aim of this study was to compare SWC and surgery patients in terms of their neurological outcomes and complications, including infections, seizures, and reoperations. METHODS This was a single-center, retrospective review of the prospectively maintained institutional traumatic brain injury and trauma registries. Included were adults who sustained an acute CGSW defined as suspected or confirmed dural penetration. Excluded were nonfirearm penetrating injuries, patients with an initial Glasgow Coma Scale (GCS) score of 3, patients with an initial GCS score of 4 and nonreactive pupils, and patients who died within 48 hours of presentation. RESULTS A total of 67 patients were included; 17 (25.4%) were treated with SWC and 50 (74.6%) were treated with surgery. The SWC group had a lower incidence of radiographic mass effect (3/17 [17.6%] SWC vs 31/50 [62%] surgery; absolute difference 44.4, 95% CI -71.9 to 16.8; p = 0.002) and lower incidence of involvement of the frontal sinus (0/17 [0%] SWC vs 14/50 [28%] surgery; absolute difference 28, 95% CI -50.4 to 5.6; p = 0.01). There were no differences in the frequency of Glasgow Outcome Scale-Extended scores ≥ 5 between the SWC and surgery groups at 30 days (4/11 [36.4%] SWC vs 12/35 [34.3%] surgery; OR 1.1, 95% CI 0.3-4.5; p > 0.99), 60 days (2/7 [28.6%] SWC vs 8/26 [30.8%] surgery; OR 0.9, 95% CI 0.3-3.4; p > 0.99), and 90 days (3/8 [37.5%] SWC vs 12/26 [46.2%] surgery; OR 0.7, 95% CI 0.1-3.6; p > 0.99). There were no differences in the incidence of infections (1/17 [5.9%] SWC vs 6/50 [12%] surgery; OR 0.5, 95% CI 0.1-4.1; p = 0.67), CSF fistulas (2/11 [11.6%] SWC vs 3/50 [6%] surgery; OR 2.1, 95% CI 0.3-13.7; p = 0.60), seizures (3/17 [17.6%] SWC vs 9/50 [18%] surgery; OR 1, 95% CI 0.2-4.1; p > 0.99), and reoperations (3/17 [17.6%] SWC vs 4/50 [8%] surgery; OR 2.5, 95% CI 0.5-12.4; p = 0.36) between the SWC and surgery groups. CONCLUSIONS There were important clinically relevant differences between the SWC and surgery groups. SWC can be considered a safe and efficacious proactive therapy in a carefully selected subset of civilian CGSW patients.
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Affiliation(s)
- Evan M Krueger
- 1Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ronald J Benveniste
- 1Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Victor M Lu
- 1Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ruby R Taylor
- 2University of Miami Miller School of Medicine, Miami, Florida; and
| | | | - Joacir G Cordeiro
- 1Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Jonathan R Jagid
- 1Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
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Antibiotic prophylaxis in penetrating traumatic brain injury: analysis of a single-center series and systematic review of the literature. Acta Neurochir (Wien) 2023; 165:303-313. [PMID: 36529784 PMCID: PMC9922212 DOI: 10.1007/s00701-022-05432-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/19/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Penetrating traumatic brain injury (pTBI) is an acute medical emergency with a high rate of mortality. Patients with survivable injuries face a risk of infection stemming from foreign body transgression into the central nervous system (CNS). There is controversy regarding the utility of antimicrobial prophylaxis in managing such patients, and if so, which antimicrobial agent(s) to use. METHODS We reviewed patients with pTBI at our institution and performed a PRISMA systematic review to assess the impact of prophylactic antibiotics on reducing risk of CNS infection. RESULTS We identified 21 local patients and 327 cases in the literature. In our local series, 17 local patients received prophylactic antibiotics; four did not. Overall, five of these patients (24%) developed a CNS infection (four and one case of intraparenchymal brain abscess and meningitis, respectively). All four patients who did not receive prophylactic antibiotics developed an infection (three with CNS infections; one superficial wound infection) compared to two of 17 (12%) patients who did receive prophylactic antibiotics. Of the 327 pTBI cases reported in the literature, 216 (66%) received prophylactic antibiotics. Thirty-eight (17%) patients who received antibiotics developed a CNS infection compared to 21 (19%) who did not receive antibiotics (p = 0.76). CONCLUSIONS Although our review of the literature did not reveal any benefit, our institutional series suggested that patients with pTBI may benefit from prophylactic antibiotics. We propose a short antibiotic course with a regimen specific to cases with and without the presence of organic debris.
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Alfawares Y, Folz C, Johnson MD, Prestigiacomo CJ, Ngwenya LB. The history of antibiotic irrigation and prophylaxis in operative neurotrauma: perpetuation of military care in civilian settings. Neurosurg Focus 2022; 53:E7. [DOI: 10.3171/2022.6.focus22253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/21/2022] [Indexed: 11/06/2022]
Abstract
The benefit of antibiotic irrigation for prophylaxis against wound infections, not only for traumatic cranial injuries but also in elective neurosurgical care, has recently been called into question. Several articles have cast doubt on the utility of topical antibiotics, and recently, bacitracin irrigation was made unavailable in some US markets. The pervasive nature of antibiotic irrigation, considering the lack of evidence supporting its use, led the authors to question when and how neurosurgeons started using antibiotic irrigation in cranial neurosurgery. Through a review of historical literature, they highlight the adoption of antibiotic irrigation as it began in battlefield surgical practice, gradually leading to the modern concept of antibiotic prophylaxis in civilian and military care.
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Affiliation(s)
| | | | - Mark D. Johnson
- College of Medicine, University of Cincinnati
- Department of Neurosurgery, University of Cincinnati; and
| | - Charles J. Prestigiacomo
- College of Medicine, University of Cincinnati
- Department of Neurosurgery, University of Cincinnati; and
| | - Laura B. Ngwenya
- College of Medicine, University of Cincinnati
- Department of Neurosurgery, University of Cincinnati; and
- Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Ohio
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5
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Kessely YC, Ndortolnan A, Toudjingar FG, Ndolembai N, Li-Iyané Ouambi O, Aggad M, Berete I, Aouami A, Dobian SR, Kader N, Berret M, Traore S, Abbassi A, Assi C, Code M. Craniocerebral Gunshot Injuries in Chad: A Study of 44 Cases. World Neurosurg 2022; 163:e458-e463. [PMID: 35398577 DOI: 10.1016/j.wneu.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Firearm head injuries cause great public health concern because of their severity. They are life-threatening due to intracranial lesions and sepsis risks. This prospective study evaluates the management of craniocerebral wounds in Chad. METHODS This is an observational study conducted over a period of 65 months with 44 patients with a ballistic craniocerebral wound (BCW), of which only 7.18% were assessed by neurosurgeons with gunshot wound. RESULTS The mean age was 30.57 ± 13 years (range:2-60 years). The 21-30 age group was the most affected (31.8%). The sex ratio was 21. A total of 63.6% of cases involved military personnel. The average admission time was 24.95 ± 12 hours (range: 1-72 hours). Explosive device attacks represented 29.5% of cases, of which 53.3% occurred in civilian practice. Point-blank shooting was reported in 70.5% of cases. The entry hole of the projectile was frontal in 40.9%. Intracranial sequestration of the projectile was found in 56.8%. Association of upper limb trauma was found in 9.1% of cases. Brain scans were performed in 95.5% of cases. Surgical treatment was undertaken in 68.18% of cases. The recovery process was marked by brain abscess in 6.8% of cases. Seven deaths were recorded. CONCLUSIONS This study shows that BCW is frequent and mainly affects young male individuals in Chad. Many of the cases were related to improvised explosive device attacks, especially in civilian practice (70.5%). The delay in diagnostic and therapeutic management favors the high rate of sequelae.
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Affiliation(s)
| | - Aser Ndortolnan
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | | | - Njesada Ndolembai
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | | | - Mourad Aggad
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Ibrahima Berete
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Aboubacar Aouami
- Division of Radiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Succés R Dobian
- Division of Radiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Ndiaye Kader
- Division of Anesthesiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Martine Berret
- Division of Anesthesiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Sorry Traore
- Division of Anesthesiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Adamou Abbassi
- Division of Anesthesiology, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Constant Assi
- Division of Medicine, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
| | - Momar Code
- Department of Neurosurgery, Hôpital 'La Renaissance de Ndjari', Ndjamena, Chad
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6
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Johnson MD, Stolz U, Carroll CP, Yang GL, Andaluz N, Foreman B, Kreitzer N, Goodman MD, Ngwenya LB. An independent, external validation and component analysis of the Surviving Penetrating Injury to the Brain score for civilian cranial gunshot injuries. J Neurosurg 2022; 137:1839-1846. [PMID: 35426813 DOI: 10.3171/2022.2.jns212256] [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: 09/22/2021] [Accepted: 02/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Surviving Penetrating Injury to the Brain (SPIN) score utilizes clinical variables to estimate in-hospital and 6-month mortality for patients with civilian cranial gunshot wounds (cGSWs) and demonstrated good discrimination (area under the receiver operating characteristic curve [AUC] 0.880) in an initial validation study. The goal of this study was to provide an external, independent validation of the SPIN score for in-hospital and 6-month mortality. METHODS To accomplish this, the authors retrospectively reviewed 6 years of data from their institutional trauma registry. Variables used to determine SPIN score were collected, including sex, transfer status, injury motive, pupillary reactivity, motor component of the Glasgow Coma Scale (mGCS), Injury Severity Score (ISS), and international normalized ratio (INR) at admission. Multivariable logistic regression analysis identified variables associated with mortality. The authors compared AUC between models by using a nonparametric test for equality. RESULTS Of the 108 patients who met the inclusion criteria, 101 had all SPIN score components available. The SPIN model had an AUC of 0.962. The AUC for continuous mGCS score alone (0.932) did not differ significantly from the AUC for the full SPIN model (p = 0.26). The AUC for continuous mGCS score (0.932) was significantly higher compared to categorical mGCS score (0.891, p = 0.005). Use of only mGCS score resulted in fewer exclusions due to missing data. No additional variable included in the predictive model alongside continuous mGCS score was a significant predictor of inpatient mortality, 6-month mortality, or increased model discrimination. CONCLUSIONS Given these findings, continuous 6-point mGCS score may be sufficient as a generalizable predictor of inpatient and 6-month mortality in patients with cGSW, demonstrating excellent discrimination and reduced bias due to missing data.
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Affiliation(s)
- Mark D Johnson
- 1Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio.,2Collaborative for Research on Acute Neurological Injury (CRANI), University of Cincinnati, Cincinnati, Ohio
| | - Uwe Stolz
- 2Collaborative for Research on Acute Neurological Injury (CRANI), University of Cincinnati, Cincinnati, Ohio.,3Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Christopher P Carroll
- 4Department of Brain & Spine Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia.,5Division of Neurosurgery, Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - George L Yang
- 1Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio.,2Collaborative for Research on Acute Neurological Injury (CRANI), University of Cincinnati, Cincinnati, Ohio
| | - Norberto Andaluz
- 1Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio
| | - Brandon Foreman
- 1Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio.,2Collaborative for Research on Acute Neurological Injury (CRANI), University of Cincinnati, Cincinnati, Ohio.,6Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Natalie Kreitzer
- 2Collaborative for Research on Acute Neurological Injury (CRANI), University of Cincinnati, Cincinnati, Ohio.,3Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio.,6Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Michael D Goodman
- 7Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Laura B Ngwenya
- 1Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio.,2Collaborative for Research on Acute Neurological Injury (CRANI), University of Cincinnati, Cincinnati, Ohio.,6Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio; and
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7
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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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Takahashi CE, Virmani D, Chung DY, Ong C, Cervantes-Arslanian AM. Blunt and Penetrating Severe Traumatic Brain Injury. Neurol Clin 2021; 39:443-469. [PMID: 33896528 DOI: 10.1016/j.ncl.2021.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.
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Affiliation(s)
- Courtney E Takahashi
- Department of Neurology, Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA.
| | - Deepti Virmani
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - David Y Chung
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA; Division of Neurocritical Care, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Neurovascular Research Unit, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Charlene Ong
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
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9
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Johnson MD, Carroll CP, Cass D, Andaluz N, Foreman B, Goodman MD, Ngwenya LB. Single-Center Experience With Antibiotic Prophylaxis and Infectious Complications in Civilian Cranial Gunshot Wounds. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okaa013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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10
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Murray L. Craniocerebral nail gun injuries: a definitive review of the literature. Brain Inj 2021; 35:164-172. [PMID: 33385306 DOI: 10.1080/02699052.2020.1867767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM Nail guns are important time saving devices but are associated with morbidity and mortality. Specifically, craniocerebral injuries have been reported in the literature since 1963 and have increased in frequency as the use of these tools has become commonplace. There remains a paucity of literature comprehensively assessing nail gun injuries, as compared with other penetrating craniocerebral injuries like those from firearms. METHOD A literature review of PubMed, Medline (Ovid), Cochrane library, and Google Scholar for articles published between 1960 and 2018 reporting craniocerebral nail gun injuries. RESULTS In total, 96 individual cases were identified, with 80 meeting inclusion criteria. These were categorized as accidental and intentional injuries. The demographic was overwhelmingly young males (97.5%), and intentional self-inflicted injuries (54%) was the most frequent mechanism of injury. Overall mortality was 10%. Mortality was more common in patients with intentional injuries, but morbidity rates were similar between the accidental and intentional injury cohorts. Post-operative complications rate was 23.8%. CONCLUSION Craniocerebral nail gun injuries are associated with lower rates of both mortality and residual neurological deficits than craniocerebral firearms injuries. There is limited data to inform clinical prognostication about long-term neurological impairments and the time to recovery which should be addressed in future studies.
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Affiliation(s)
- Lewis Murray
- Division of Surgery & Perioperative Medicine, Flinders Medical Centre, Bedford Park, Australia
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11
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Acute and Long-Term Complications of Gunshot Wounds to the Head. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00301-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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12
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Platt A, Collins J, Horowitz PM. Cranial Vault Reconstruction and Evacuation of Hemorrhage After a Bifrontal Gunshot Wound to the Brain. World Neurosurg 2020; 138:408-410. [PMID: 32247791 DOI: 10.1016/j.wneu.2020.03.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/22/2020] [Accepted: 03/23/2020] [Indexed: 11/29/2022]
Abstract
Civilian gunshot wounds to the brain are associated with high overall mortality; however, outcomes can vary significantly depending on bullet trajectory. This report details the outcome of a patient who sustained a bifrontal gunshot wound with multiple associated calvarial and frontal sinus fractures. Although surgery for penetrating brain injury is most frequently employed for relief of mass effect and decompression of vital structures, this case report describes a more comprehensive technique involving duroplasty, obliteration of the frontal sinus, and cranial vault reconstruction with the aim of decreasing the rate of cerebrospinal fluid leak, infection, reoperation, and readmission.
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Affiliation(s)
- Andrew Platt
- Department of Surgery, Section of Neurosurgery, University of Chicago, Chicago, Illinois, USA.
| | - John Collins
- Department of Radiology, University of Chicago, Chicago, Illinois, USA
| | - Peleg M Horowitz
- Department of Surgery, Section of Neurosurgery, University of Chicago, Chicago, Illinois, USA
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13
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Loggini A, Vasenina VI, Mansour A, Das P, Horowitz PM, Goldenberg FD, Kramer C, Lazaridis C. Management of civilians with penetrating brain injury: A systematic review. J Crit Care 2020; 56:159-166. [DOI: 10.1016/j.jcrc.2019.12.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/05/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022]
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14
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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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Okochi M, Komuro Y, Ueda K. Emergency microsurgery for patients with soft tissue, skull, and dura complex defects after trauma: a case report. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2019; 6:99-104. [PMID: 31840036 PMCID: PMC6896475 DOI: 10.1080/23320885.2019.1691922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/07/2019] [Indexed: 11/06/2022]
Abstract
We performed two emergency microsurgical dura, skull, and scalp complex reconstructions. We used the rectus abdominis flap with free fascia lata and the anterolateral thigh flap with vascularized fascia lata. To achieve good postoperative result, reconstruction should be performed before meningitis or wound infection.
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Affiliation(s)
- Masayuki Okochi
- Department of Plastic and Reconstructive Surgery, Teikyo University, Tokyo Japan
| | - Yuzo Komuro
- Department of Plastic and Reconstructive Surgery, Teikyo University, Tokyo Japan
| | - Kazuki Ueda
- Department of Plastic and Reconstructive Surgery, Teikyo University, Tokyo Japan
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16
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Älgå A, Wong S, Shoaib M, Lundgren K, Giske CG, von Schreeb J, Malmstedt J. Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan. BMC Infect Dis 2018; 18:233. [PMID: 29788910 PMCID: PMC5964734 DOI: 10.1186/s12879-018-3149-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 05/15/2018] [Indexed: 11/30/2022] Open
Abstract
Background Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared. Methods We performed a cohort study using routinely collected data from 457 consecutive Syrian civilians that received surgical treatment for acute conflict-related injuries during 2014–2016 at a Jordanian hospital supported by Médecins Sans Frontières. We defined wound infection as clinical signs of infection verified by a positive culture. We used logistic regression models to evaluate infection-related differences in outcome and resource consumption. Results Wound infection was verified in 49/457 (11%) patients. Multidrug-resistance (MDR) was detected in 36/49 (73%) of patients with infection. Among patients with infection, 11/49 (22%) were amputated, compared to 37/408 (9%) without infection, crude relative risk = 2.62 (95% confidence interval 1.42–4.81). Infected patients needed 12 surgeries on average, compared to five in non-infected patients (p < .00001). Mean length of stay was 77 days for patients with infection, and 35 days for patients without infection (p = .000001). Conclusions Among Syrian civilians, infected conflict-related wounds had a high prevalence of MDR bacteria. Wound infection was associated with poor outcomes and high resource consumption. These results could guide the development of antibiotic protocols and adaptations of surgical management to improve care for wound infections in conflict-related injuries. Trial registration ClinicalTrials.gov (NCT02744144). Registered April 13, 2016. Retrospectively registered.
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Affiliation(s)
- Andreas Älgå
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Sidney Wong
- Médecins Sans Frontières, Operational Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Kalle Lundgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Malmstedt
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Classification of Pathogenic Bacteria in Cerebrospinal Fluid of Patients with Intracranial Infection After Neurosurgery and Selective Use of Antibacterial Agents. Jundishapur J Microbiol 2018. [DOI: 10.5812/jjm.60788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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19
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Cerebrospinal fluid and brain extracellular fluid in severe brain trauma. HANDBOOK OF CLINICAL NEUROLOGY 2018; 146:237-258. [DOI: 10.1016/b978-0-12-804279-3.00014-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Knockdown of miR-155 protects microglia against LPS-induced inflammatory injury via targeting RACK1: a novel research for intracranial infection. JOURNAL OF INFLAMMATION-LONDON 2017; 14:17. [PMID: 28804270 PMCID: PMC5549339 DOI: 10.1186/s12950-017-0162-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 07/05/2017] [Indexed: 11/17/2022]
Abstract
Background Intracranial infection, one of the complications of traumatic brain injury, is usually associated with inflammation. Several microRNAs (miRNAs), including miR-155, have been reported to be critical modulators in peripheral and central nervous system inflammation. In this study, we investigated the role of miR-155 in lipopolysaccharide (LPS)-induced inflammatory injury in mouse microglia BV2 cells. Results The expression level of miR-155 was significantly up-regulated after LPS stimulation in BV2 cells. LPS administration decreased BV2 cell viability, promoted apoptosis and increased the release of pro-inflammatory cytokines; while miR-155 knockdown rescued BV2 cell from LPS-induced injury. RACK1 was a directly target of miR-155. Interestingly, miR-155 knockdown did not attenuate LPS-induced inflammatory injury when RACK1 was knocked down. The mechanistic study indicated that miR-155 knockdown deactivated MAPK/NF-κB and mTOR signaling pathways under LPS-treated conditions. Conclusions Knockdown of miR-155 protected mouse microglia BV2 cells from LPS-induced inflammatory injury via targeting RACK1 and deactivating MAPK/NF-κB and mTOR signaling pathways.
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Etheridge JC, Vignali JD, Collins JN. Duration of Antibiotic Prophylaxis in Patients with Gunshot Wounds to the Head. Am Surg 2017. [DOI: 10.1177/000313481708300802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- James C. Etheridge
- Department of Surgery Division of Trauma and Critical Care Eastern Virginia Medical School Norfolk, Virginia
| | - Jonathan D. Vignali
- Department of Surgery Division of Trauma and Critical Care Eastern Virginia Medical School Norfolk, Virginia
| | - Jay N. Collins
- Department of Surgery Division of Trauma and Critical Care Eastern Virginia Medical School Norfolk, Virginia
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Caporlingua A, Caporlingua F, Lenzi J. Good outcome after delayed surgery for orbitocranial non-missile penetrating brain injury. Asian J Neurosurg 2016; 11:309. [PMID: 27366265 PMCID: PMC4849307 DOI: 10.4103/1793-5482.179641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Nonmissile orbitocranial penetrating brain injuries are uncommonly dealt with in a civilian context. Surgical management is controversial, due to the lack of widely accepted guidelines. A 52-year-old man was hit in his left eye by a metallic foreign body (FB). Head computed tomography (CT) scan showed a left subcortical parietal FB with a considerable hemorrhagic trail originating from the left orbital roof. Surgical treatment was staged; an exenteratio oculi and a left parietal craniotomy to extract the FB under intraoperative CT guidance were performed at post trauma day third and sixth, respectively. A postoperative infectious complication was treated conservatively. The patient retained a right hemiparesis (3/5) and was transferred to rehabilitation in good clinical conditions at day 49th. He had suspended antiepilectic therapy at that time. A case-by-case tailored approach is mandatory to achieve the best outcome in such a heterogeneous nosological entity. Case reporting is crucial to further understand its mechanism and dynamics.
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Affiliation(s)
- Alessandro Caporlingua
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
| | - Federico Caporlingua
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
| | - Jacopo Lenzi
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
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Lu H, Wang L, Zhong W, Qi R, Li N, You W, Su X, Zhuang Z, Cheng H, Shi J. Establishment of swine-penetrating craniocerebral gunshot wound model. J Surg Res 2015; 199:698-706. [DOI: 10.1016/j.jss.2015.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 12/17/2014] [Accepted: 01/07/2015] [Indexed: 10/24/2022]
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Alvis-Miranda HR, Adie Villafañe R, Rojas A, Alcala-Cerra G, Moscote-Salazar LR. Management of Craniocerebral Gunshot Injuries: A Review. Korean J Neurotrauma 2015; 11:35-43. [PMID: 27169063 PMCID: PMC4847495 DOI: 10.13004/kjnt.2015.11.2.35] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 04/01/2015] [Accepted: 04/10/2015] [Indexed: 11/15/2022] Open
Abstract
Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately this is a prevalent condition in developing countries, with major armed conflicts which is not very likely to achieve a high rate of prevention. Management goals should focus on early aggressive, vigorous resuscitation and correction of coagulopathy; those with stable vital signs undergo brain computed tomography scan. Neuroimaging is vital for surgical purposes, especially for determine type surgery, size and location of the approach, route of extraction of the foreign body; however not always surgical management is indicated, there is also the not uncommon decision to choose non-surgical management. The treatment consist of immediate life salvage, through control of persistent bleeding and cerebral decompression; prevention of infection, through extensive debridement of all contaminated, macerated or ischemic tissues; preservation of nervous tissue, through preventing meningocerebral scars; and restoration of anatomic structures through the hermetic seal of dura and scalp. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients; classic studies in military and civil environment have identified that this is a highly lethal or devastating violent condition, able to leave marked consequences for the affected individual, the family and the health system itself. Various measures have been aimed to lower the incidence of CGI, especially in civilians. It is necessarily urgent to promote research in a neurocritical topic such as CGI, looking impact positively the quality of life for those who survive.
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Affiliation(s)
| | | | - Alejandro Rojas
- Department of Neurosurgery, FUSC, Hospital San Jose, Bogota, Colombia
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Zhou L, Lin J, Lin J, Kui G, Zhang J, Yu Y. Neuroprotective effects of vagus nerve stimulation on traumatic brain injury. Neural Regen Res 2014; 9:1585-91. [PMID: 25368644 PMCID: PMC4211199 DOI: 10.4103/1673-5374.141783] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2014] [Indexed: 11/15/2022] Open
Abstract
Previous studies have shown that vagus nerve stimulation can improve the prognosis of traumatic brain injury. The aim of this study was to elucidate the mechanism of the neuroprotective effects of vagus nerve stimulation in rabbits with brain explosive injury. Rabbits with brain explosive injury received continuous stimulation (10 V, 5 Hz, 5 ms, 20 minutes) of the right cervical vagus nerve. Tumor necrosis factor-α, interleukin-1β and interleukin-10 concentrations were detected in serum and brain tissues, and water content in brain tissues was measured. Results showed that vagus nerve stimulation could reduce the degree of brain edema, decrease tumor necrosis factor-α and interleukin-1β concentrations, and increase interleukin-10 concentration after brain explosive injury in rabbits. These data suggest that vagus nerve stimulation may exert neuroprotective effects against explosive injury via regulating the expression of tumor necrosis factor-α, interleukin-1β and interleukin-10 in the serum and brain tissue.
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Affiliation(s)
- Long Zhou
- Affiliated Dongnan Hospital of Xiamen University, the 175 Hospital of Chinese PLA, Trauma Neurosurgery Center of Nanjing Military Region, Xiamen, Fujian Province, China
| | - Jinhuang Lin
- Affiliated Dongnan Hospital of Xiamen University, the 175 Hospital of Chinese PLA, Trauma Neurosurgery Center of Nanjing Military Region, Xiamen, Fujian Province, China
| | - Junming Lin
- Affiliated Dongnan Hospital of Xiamen University, the 175 Hospital of Chinese PLA, Trauma Neurosurgery Center of Nanjing Military Region, Xiamen, Fujian Province, China
| | - Guoju Kui
- Affiliated Dongnan Hospital of Xiamen University, the 175 Hospital of Chinese PLA, Trauma Neurosurgery Center of Nanjing Military Region, Xiamen, Fujian Province, China
| | - Jianhua Zhang
- The 73131 Corps of Chinese PLA, Xiamen, Fujian Province, China
| | - Yigang Yu
- Affiliated Dongnan Hospital of Xiamen University, the 175 Hospital of Chinese PLA, Trauma Neurosurgery Center of Nanjing Military Region, Xiamen, Fujian Province, China
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