1
|
Nadeem A, Siddiqui T, Rais T, Munsab R, Habib A, Afridi EK, Shariq F. Comparing surgical outcomes: Craniotomy versus decompressive craniectomy in acute subdural hematoma - A systematic review and meta-analysis. World Neurosurg X 2024; 23:100368. [PMID: 38623315 PMCID: PMC11017056 DOI: 10.1016/j.wnsx.2024.100368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 03/20/2024] [Indexed: 04/17/2024] Open
Abstract
Introduction Acute subdural hematomas (SDH) pose a significant health risk, often resulting from traumatic head injuries. The choice between surgical interventions, craniotomy, and decompressive craniectomy, remains a subject of debate. This meta-analysis aims to compare outcomes and guide clinical decision-making. Methods Following PRISMA guidelines, a comprehensive literature search was conducted in databases such as Ovid Medline, PubMed, and Cochrane, up to December 2023. Selection criteria included studies comparing craniotomy and decompressive craniectomy for acute SDH. Data extraction utilized the Newcastle-Ottawa Quality Assessment Tool, and statistical analysis employed the random-effects model. Results The meta-analysis included 17 studies and 6848 patients. Craniotomy demonstrated a significant reduction in mortality rates (RR 0.80, 95% CI 0.73-0.89, P < 0.0001). GCS scores favored craniotomy for severe cases. GOS outcomes showed a trend favoring craniotomy, particularly in good recovery (RR 1.34, 95% CI 1.04-1.74, P = 0.03). Additional factors explored included co-existing sub-epidural hematoma, mydriasis, extracranial injuries, residual SDH, revision rates, and intracranial pressure. Conclusion The meta-analysis suggests that craniotomy may be a favorable surgical strategy for acute SDH, displaying a significant decrease in mortality rates and a lower risk of raised intracranial pressure. However, the nuanced nature of outcomes emphasizes the need for a tailored approach, considering broader clinical contexts. Future research should address limitations and provide a basis for well-informed clinical decision-making.
Collapse
Affiliation(s)
- Abdullah Nadeem
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Taruba Rais
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | - Rabbia Munsab
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | - Ashna Habib
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | | | - Fariha Shariq
- Karachi Medical and Dental College, Karachi, Pakistan
| |
Collapse
|
2
|
Enomoto N, Matsuzaki K, Matsuda T, Yamaguchi T, Miyamoto T, Hanaoka M, Teshima N, Kageyama A, Satoh Y, Haboshi T, Korai M, Shimada K, Niki H, Satoh K, Takagi Y. Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma. Acta Neurochir (Wien) 2024; 166:272. [PMID: 38888676 DOI: 10.1007/s00701-024-06167-y] [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: 02/01/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. METHODS From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. RESULTS Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. CONCLUSIONS The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.
Collapse
Affiliation(s)
- Noriya Enomoto
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan.
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan.
| | - Kazuhito Matsuzaki
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Tomohiro Matsuda
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Tadashi Yamaguchi
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Takeshi Miyamoto
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Mami Hanaoka
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Natsumi Teshima
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Ayato Kageyama
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yuichi Satoh
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Tatsuya Haboshi
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Masaaki Korai
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Kenji Shimada
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Hitoshi Niki
- Department of Neurology, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Koichi Satoh
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| |
Collapse
|
3
|
Pyne S, Barton G, Turner D, Mee H, Gregson BA, Kolias AG, Turner C, Adams H, Mohan M, Uff C, Hasan S, Wilson M, Bulters DO, Zolnourian A, McMahon C, Stovell MG, Al-Tamimi Y, Thomson S, Viaroli E, Belli A, King A, Helmy AE, Timofeev I, Menon D, Hutchinson PJ. Cost-effectiveness of craniotomy versus decompressive craniectomy for UK patients with traumatic acute subdural haematoma. BMJ Open 2024; 14:e085084. [PMID: 38885989 DOI: 10.1136/bmjopen-2024-085084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE To estimate the cost-effectiveness of craniotomy, compared with decompressive craniectomy (DC) in UK patients undergoing evacuation of acute subdural haematoma (ASDH). DESIGN Economic evaluation undertaken using health resource use and outcome data from the 12-month multicentre, pragmatic, parallel-group, randomised, Randomised Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation-ASDH trial. SETTING UK secondary care. PARTICIPANTS 248 UK patients undergoing surgery for traumatic ASDH were randomised to craniotomy (N=126) or DC (N=122). INTERVENTIONS Surgical evacuation via craniotomy (bone flap replaced) or DC (bone flap left out with a view to replace later: cranioplasty surgery). MAIN OUTCOME MEASURES In the base-case analysis, costs were estimated from a National Health Service and Personal Social Services perspective. Outcomes were assessed via the quality-adjusted life-years (QALY) derived from the EuroQoL 5-Dimension 5-Level questionnaire (cost-utility analysis) and the Extended Glasgow Outcome Scale (GOSE) (cost-effectiveness analysis). Multiple imputation and regression analyses were conducted to estimate the mean incremental cost and effect of craniotomy compared with DC. The most cost-effective option was selected, irrespective of the level of statistical significance as is argued by economists. RESULTS In the cost-utility analysis, the mean incremental cost of craniotomy compared with DC was estimated to be -£5520 (95% CI -£18 060 to £7020) with a mean QALY gain of 0.093 (95% CI 0.029 to 0.156). In the cost-effectiveness analysis, the mean incremental cost was estimated to be -£4536 (95% CI -£17 374 to £8301) with an OR of 1.682 (95% CI 0.995 to 2.842) for a favourable outcome on the GOSE. CONCLUSIONS In a UK population with traumatic ASDH, craniotomy was estimated to be cost-effective compared with DC: craniotomy was estimated to have a lower mean cost, higher mean QALY gain and higher probability of a more favourable outcome on the GOSE (though not all estimated differences between the two approaches were statistically significant). ETHICS Ethical approval for the trial was obtained from the North West-Haydock Research Ethics Committee in the UK on 17 July 2014 (14/NW/1076). TRIAL REGISTRATION NUMBER ISRCTN87370545.
Collapse
Affiliation(s)
- Sarah Pyne
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Garry Barton
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - David Turner
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Harry Mee
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Barbara A Gregson
- Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Angelos G Kolias
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Carole Turner
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Hadie Adams
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Midhun Mohan
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Mark Wilson
- Department of Neurosurgery, St Mary's Hospital, London, UK
| | | | | | - Catherine McMahon
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Matthew G Stovell
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Yahia Al-Tamimi
- Department of Neurosurgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Thomson
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Edoardo Viaroli
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Antonio Belli
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew King
- Department of Neurosurgery, Salford Royal Hospital Manchester Centre for Clinical Neurosciences, Salford, UK
| | - Adel E Helmy
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Ivan Timofeev
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Peter John Hutchinson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| |
Collapse
|
4
|
Shoaib A, Hussain F, Khan M, Sohail A, Hasnain Panjwani M, Talal Ashraf M, Choudhary A. Comparative efficacy of craniotomy versus craniectomy in surgical management of acute subdural hematoma: A systematic review and meta-analysis. J Clin Neurosci 2024; 124:154-168. [PMID: 38718611 DOI: 10.1016/j.jocn.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Acute subdural hematoma (ASDH), a predominantly lethal neurosurgical emergency in the settings of traumatic brain injury, requires surgical evacuation of hematoma, via craniotomy or craniectomy. The clinical practices vary, with no consensus over the superiority of either procedure. AIM To evaluate whether craniotomy or craniectomy is the optimal approach for surgical evacuation of ASDH. METHODS After a comprehensive search of PubMed, Google Scholar, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) up to January 2024, to identify relevant studies, a meta-analysis was performed using a random-effects model, and risk ratios were calculated with 95% confidence intervals (CIs). For quality assessment, the Cochrane risk of bias tool and Newcastle-Ottawa Scale were applied. RESULTS Out of 2143 potentially relevant studies, 1875 were deemed suitable for screening. Eighteen studies were included in the systematic review. Thirteen studies, in which 1589 patients underwent craniotomy and 1452 patients underwent craniectomy, allowed meta-analysis. Pooled estimates showed that there was no significant correlation of mortality at 6 months (RR 1.14;95 % CI; 0.94-1.38 P = 0.18) and 12 months (RR 1.17; 95 % CI; 0.84-1.63 P = 0.36) with the two surgical modalities. A positive association was observed between improved functional outcomes at 6-months and craniotomy (RR 0.76; 95 % CI; 0.62-0.93 P = 0.008), however, no significant difference was observed between the two treatment groups at 12 months follow-up (RR 0.89; 95 % CI; 0.72-1.09 P = 0.26). Craniotomy reported a significantly higher proportion of patients discharged to home (RR 0.63; 95 % CI; 0.49-0.83 P = 0.0007), whereas incidence of residual subdural hematoma was significantly lower in the craniectomy group (RR 0.70; 95 % CI; 0.52-0.94 P = 0.02). CONCLUSION Craniectomy is associated with poor clinical outcomes. However, with long-term follow-up, no difference in mortality and functional outcomes is observed in either of the patient populations. On account of equivocal evidence regarding the efficacy of craniectomy over craniotomy in the realm of long-term outcomes, utmost preference shall be directed toward craniotomy as it is less invasive and associated with fewer complications.
Collapse
Affiliation(s)
- Areeba Shoaib
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan.
| | - Fakiha Hussain
- Department of Medicine, Liaquat College of Medicine and Dentistry, Karachi, Pakistan
| | - Maryam Khan
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Affan Sohail
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | | | - Anood Choudhary
- Department of Medicine, Karachi Medical and Dental College, Karachi, Pakistan.
| |
Collapse
|
5
|
Podell JE, Morris NA. Traumatic Brain Injury and Traumatic Spinal Cord Injury. Continuum (Minneap Minn) 2024; 30:721-756. [PMID: 38830069 DOI: 10.1212/con.0000000000001423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury. LATEST DEVELOPMENTS Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated. ESSENTIAL POINTS Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.
Collapse
|
6
|
Yang J, Shen M. Comparison of Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma: A Systematic Review and Meta-Analysis. World Neurosurg 2024:S1878-8750(24)00844-1. [PMID: 38777321 DOI: 10.1016/j.wneu.2024.05.081] [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: 05/03/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Acute subdural hematoma (ASDH) is a common critical neurosurgical condition, often requiring immediate surgical intervention. Craniotomy and decompressive craniectomy are the 2 mainstay surgical approaches. This comprehensive review and meta-analysis aims to summarize the existing evidence and compare the outcomes of these 2 procedures. METHODS PubMed, Embase, Cochrane Central Register of Controlled Trials, and CINAHL electronic databases were searched for relevant studies, published between inception of databases till June 2023. Eligible studies reported data of patients diagnosed with ASDH who underwent craniotomy or decompressive craniectomy for ASDH. Outcome measures included the Glasgow Coma Scale score, residual subdural hematoma, requirement of revision surgery, poorer outcomes, and mortality. Data were presented as pooled odds ratios with 95% confidence intervals. Quality assessment and risk of bias were performed for each study. RESULTS Fourteen studies with a total of 3095 patients were included. The results showed that patients who underwent craniotomy had significantly lower mortality, lower odds of poorer outcomes, and a higher rate of residual subdural hematoma, compared to patients who underwent decompressive craniectomy. There was no significant difference in the requirement of revision surgery between the 2 groups. Heterogeneity was high for most outcomes, and the quality of evidence ranged from moderate to low. CONCLUSION Our findings suggest that craniotomy is associated with better clinical outcomes and lower mortality compared to decompressive craniectomy for ASDH, but a higher rate of residual subdural hematoma. Further high-quality randomized controlled trials are needed to validate our findings.
Collapse
Affiliation(s)
- Jingjing Yang
- Department of Neurology 707A, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang China
| | - Min Shen
- Department of Neurology 707A, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang China.
| |
Collapse
|
7
|
Gkantsinikoudis N, Monioudis P, Antoniades E, Tsitouras V, Magras I. Fatal postoperative tension pneumocephalus after acute subdural hematoma evacuation: a case report. Int J Neurosci 2024:1-6. [PMID: 38716712 DOI: 10.1080/00207454.2024.2352767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH). CASE PRESENTATION An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day. CONCLUSION TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.
Collapse
Affiliation(s)
- Nikolaos Gkantsinikoudis
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Monioudis
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elias Antoniades
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vassilios Tsitouras
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Magras
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
8
|
Mower WR, Akie TE, Morizadeh N, Gupta M, Hendey GW, Wilson JL, Leonid Duvergne LP, Ma P, Krishna P, Rodriguez RM. Blunt Head Injury in the Elderly: Analysis of the NEXUS II Injury Cohort. Ann Emerg Med 2024; 83:457-466. [PMID: 38340132 DOI: 10.1016/j.annemergmed.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/06/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Changes with aging make older patients vulnerable to blunt head trauma and alter the potential for injury and the injury patterns seen among this expanding cohort. High-quality care requires a clear understanding of the factors associated with blunt head injuries in the elderly. Our objective was to develop a detailed assessment of the injury mechanisms, presentations, injury patterns, and outcomes among older blunt head trauma patients. METHODS We conducted a planned secondary analysis of patients aged 65 or greater who were enrolled in the National Emergency X-Radiography Utilization Study (NEXUS) Head Computed Tomography validation study. We performed a detailed assessment of the demographics, mechanisms, presentations, injuries, interventions, and outcomes among older patients. RESULTS We identified 3,659 patients aged 65 years or greater, among the 11,770 patients enrolled in the NEXUS validation study. Of these older patients, 325 (8.9%) sustained significant injuries, as compared with significant injuries in 442 (5.4%) of the 8,111 younger patients. Older females (1,900; 51.9%) outnumbered older males (1,753; 47.9%), and occult presentations (exhibiting no high-risk clinical criteria beyond age) occurred in 48 (14.8%; 95% confidence interval (CI) 11.1 to 19.1) patients with significant injuries. Subdural hematomas (377 discreet lesions in 299 patients) and subarachnoid hemorrhages (333 discreet instances in 256 patients) were the most frequent types of injuries occurring in our elderly population. A ground-level fall was the most frequent mechanism of injury among all patients (2,211; 69.6%), those sustaining significant injuries (180; 55.7%), and those who died of their injuries (37; 46.3%), but mortality rates were highest among patients experiencing a fall from a ladder (11.8%; 4 deaths among 34 cases [95% CI 3.3% to 27.5%]) and automobile versus pedestrian events (10.7%; 16 deaths among 149 cases [95% CI 6.3% to 16.9%]). Among older patients who required neurosurgical intervention for their injuries, only 16.4% (95% CI 11.1% to 22.9%) were able to return home, 32.1% (95% CI 25.1% to 39.8%) required extended facility care, and 41.8% (95% CI 34.2% to 49.7%) died from their injuries. CONCLUSIONS Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.
Collapse
Affiliation(s)
- William R Mower
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Thomas E Akie
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA
| | | | - Malkeet Gupta
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Emergency Medicine, Antelope Valley Medical Center, Lancaster, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jake L Wilson
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Phillip Ma
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Pravin Krishna
- Department of Emergency Medicine, Antelope Valley Medical Center, Lancaster, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
| |
Collapse
|
9
|
Serra R, Chryssikos T. Decompressive craniectomy incisions: all roads lead to bone. Br J Neurosurg 2024:1-8. [PMID: 38651499 DOI: 10.1080/02688697.2024.2344759] [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: 01/15/2024] [Accepted: 04/14/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Decompressive craniectomy and craniotomy are among the most common procedures in Neurosurgery. In recent years, increased attention has focused on the relationships between incision type, extent of decompression, vascular supply to the scalp, cosmetic outcomes, and complications. Here, we review the current literature on scalp incisions for large unilateral front-temporo-parietal craniotomies and craniectomies. METHODS Publications in the past 50 years on scalp incisions used for front-temporo-parietal craniectomies/craniotomies were reviewed. Only full texts were considered in the final analysis. A total of 27 studies that met the criteria were considered for the final manuscript. PRISMA guidelines were adopted for this study. RESULTS Five main incision types have been described. In addition to the question mark incision, other common incisions include the T-Kempe, developed to obtain wide access to the skull, the retroauricular incision, designed to spare the occipital branch, as well as the N-shaped and cloverleaf incisions which integrate with pterional approaches. Advantages and drawbacks, integration with existing incisions, relationships with the main arteries, cosmetic outcomes, and risks of wound complications including dehiscence, necrosis, and infection were assessed. DISCUSSION The reverse-question mark incision, despite being a mainstay of trauma neurosurgery, can place the vascular supply to the scalp at risk and favor wound dehiscence and infection. Several incisions, such as the T-Kempe, retroauricular, N-shaped, and cloverleaf approaches have been developed to preserve the main vessels supplying the scalp. Incision choice needs to be carefully weighted based on the patient's anatomy, position and size of main vessels, risk of wound dehiscence, and desired volume of decompression.
Collapse
Affiliation(s)
- Riccardo Serra
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | | |
Collapse
|
10
|
Keeves J, Gadowski A, McKimmie A, Bagg MK, Antonic-Baker A, Hicks AJ, Clarke N, Brown A, McNamara R, Reeder S, Roman C, Jeffcote T, Romero L, Hill R, Ponsford JL, Lannin NA, O'Brien TJ, Cameron PA, Rushworth N, Fitzgerald M, Gabbe BJ, Cooper DJ. The Australian Traumatic Brain Injury Initiative: Systematic Review of the Effect of Acute Interventions on Outcome for People With Moderate-Severe Traumatic Brain Injury. J Neurotrauma 2024. [PMID: 38279797 DOI: 10.1089/neu.2023.0465] [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: 01/29/2024] Open
Abstract
The Australian Traumatic Brain Injury Initiative (AUS-TBI) is developing a data resource to enable improved outcome prediction for people with moderate-severe TBI (msTBI) across Australia. Fundamental to this resource is the collaboratively designed data dictionary. This systematic review and consultation aimed to identify acute interventions with potential to modify clinical outcomes for people after msTBI, for inclusion in a data dictionary. Standardized searches were implemented across bibliographic databases from inception through April 2022. English-language reports of randomized controlled trials (RCTs) evaluating any association between any acute intervention and clinical outcome in at least 100 patients with msTBI, were included. A predefined algorithm was used to assign a value to each observed association. Consultation with AUS-TBI clinicians and researchers formed the consensus process for interventions to be included in a single data dictionary. Searches retrieved 14,455 records, of which 124 full-length RCTs were screened, with 35 studies included. These studies evaluated 26 unique acute interventions across 21 unique clinical outcomes. Only 4 interventions were considered to have medium modifying value for any outcome from the review, with an additional 8 interventions agreed upon through the consensus process. The interventions with medium value were tranexamic acid and phenytoin, which had a positive effect on an outcome; and decompressive craniectomy surgery and hypothermia, which negatively affected outcomes. From the systematic review and consensus process, 12 interventions were identified as potential modifiers to be included in the AUS-TBI national data resource.
Collapse
Affiliation(s)
- Jemma Keeves
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adelle Gadowski
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ancelin McKimmie
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Matthew K Bagg
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health Sciences and Physiotherapy, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Ana Antonic-Baker
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nyssa Clarke
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alastair Brown
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Rob McNamara
- School of Medicine, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sandy Reeder
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Toby Jeffcote
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | | | - Regina Hill
- Regina Hill Effective Consulting Pty. Ltd., Melbourne, Victoria, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| |
Collapse
|
11
|
Maiga AW, Cook M, Nordness MF, Gao Y, Rakhit S, Rivera EL, Harrell FE, Sharp KW, Patel MB. Surrogate Perception of Disability after Hospitalization for Traumatic Brain Injury. J Am Coll Surg 2024; 238:589-597. [PMID: 38214447 PMCID: PMC10947846 DOI: 10.1097/xcs.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND The Glasgow Outcome Scale Extended (GOSE) is a measure of recovery after traumatic brain injury (TBI). Public surveys rate some GOSE states as worse than death. Direct family experience caring for patients with TBI may impact views of post-TBI disability. STUDY DESIGN We conducted a national cross-sectional computer-adaptive survey of surrogates of TBI dependents incurring injury more than 1 year earlier. Using a standard gamble approach in randomized order, surrogates evaluated preferences for post-TBI GOSE states from GOSE 2 (bedridden, unaware) to GOSE 8 (good recovery). We calculated median (interquartile range [IQR]) health utilities for each post-TBI state, ranging from -1 to 1, with 0 as reference (death = GOSE 1), and assessed sociodemographic associations using proportional odds logistic regression modeling. RESULTS Of 515 eligible surrogates, 298 (58%) completed scenarios. Surrogates were median aged 46 (IQR 35 to 60), 54% married, with Santa Clara strength of faith 14 (10 to 18). TBI dependents had a median GOSE5 (3 to 7). Median (IQR) health utility ratings for GOSE 2, GOSE 3, and GOSE 4 were -0.06 (-0.50 to -0.01), -0.01 (-0.30 to 0.45), and 0.30 (-0.01 to 0.80), rated worse than death by 91%, 65%, and 40%, respectively. Surrogates rated GOSE 4 (daily partial help) worse than the general population. Married surrogates rated GOSE 4 higher (p < 0.01). Higher strength of faith was associated with higher utility scores across GOSE states (p = 0.034). CONCLUSIONS In this index study of surrogate perceptions about disability after TBI, poor neurologic outcomes-vegetative, needing all-day or partial daily assistance-were perceived as worse than death by at least 1 in 3 surrogates. Surrogate perceptions differed from the unexposed public. Long-term perceptions about post-TBI disability may inform earlier, tailored shared decision-making after neurotrauma.
Collapse
Affiliation(s)
- Amelia W. Maiga
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
- Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN 37203
| | - Madison Cook
- Department of Surgery, Temple University Hospital, 3401 N. Broad Street, Parkinson Pavilion, Suite 400, Philadelphia, PA 19140
| | - Mina F. Nordness
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
| | - Yue Gao
- Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN 37203
| | - Shayan Rakhit
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
- Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN 37203
| | - Erika L. Rivera
- Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN 37203
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
| | - Frank E. Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN 37203
| | - Kenneth W. Sharp
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
| | - Mayur B. Patel
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
- Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN 37203
- Vanderbilt University Medical Center; Geriatric Research Education and Clinical Center; Surgical Services, Tennessee Valley Healthcare System
| |
Collapse
|
12
|
Jussen D, Saeed S, Jablonski T, Krenzlin H, Lucia K, Kraemer T, Kempski O, Czabanka M, Ringel F, Alessandri B. Influence of Blood Components on Neuroinflammation, Blood-Brain Barrier Breakdown, and Functional Damage After Acute Subdural Hematoma in Rats. Neurotrauma Rep 2024; 5:215-225. [PMID: 38463418 PMCID: PMC10924060 DOI: 10.1089/neur.2023.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
A central component of injury development after acute subdural hematoma (ASDH) is the increased intracranial pressure and consecutive mechanical reduction of cerebral blood flow (CBF). However, the role of different blood constituents in ASDH as additional lesioning factors remains unclear. This study examines the influence of blood components on neuroinflammation, blood-brain barrier (BBB) breakdown, and functional deficits in a rat model of ASDH. We infused corpuscular (whole blood, whole blood lysate, and red cell blood) and plasmatic (blood plasma, anticoagulated blood plasma, and aqueous isotonic solution) blood components into the subdural space while CBF was monitored. Rats then underwent behavioral testing. Lesion analysis and immunohistochemistry were performed 2 days after ASDH. Inflammatory reaction was assessed using staining for ionized calcium-binding adaptor molecule 1 and glial fibrillary acidic protein, interleukin-1ß, tumor necrosis factor-alpha, and membrane attack complex. Integrity of the BBB was evaluated with albumin and matrix metalloproteinase 9 (MMP9) staining. We observed a significant drop in CBF in the corpuscular group (75% ± 7.5% of baseline) with distinct post-operative deficits and larger lesion volume compared to the plasmatic group (13.6 ± 5.4 vs. 1.3 ± 0.4 mm3). Further, inflammation was significantly increased in the corpuscular group with stronger immunoreaction. After whole blood infusion, albumin and MMP9 immunoreaction were significantly increased, pointing toward a disrupted BBB. The interaction between corpuscular and plasmatic blood components seems to be a key factor in the detrimental impact of ASDH. This interaction results in neuroinflammation and BBB leakage. These findings underscore the importance of performing surgery as early as possible and also provide indications for potential pharmacological targets.
Collapse
Affiliation(s)
- Daniel Jussen
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Syamend Saeed
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Tatjana Jablonski
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Harald Krenzlin
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Kristin Lucia
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Tobias Kraemer
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Oliver Kempski
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| | - Beat Alessandri
- Johannes Gutenberg University, Institute for Neurosurgical Pathophysiology, Mainz, Germany
- Department of Neurosurgery, University Medical Center Mainz, Mainz, Germany
| |
Collapse
|
13
|
Shafique MA, Mustafa MS, Luke-Wold B, Kumar A, Rangwala BS, Abdullah M, Ali SMS, Iqbal J, Haseeb A. Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy. Acta Neurochir (Wien) 2024; 166:121. [PMID: 38436794 DOI: 10.1007/s00701-024-06013-1] [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: 12/18/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy. MATERIALS AND METHODS We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes. RESULTS We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04). CONCLUSION Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.
Collapse
Affiliation(s)
- Muhammad Ashir Shafique
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan.
| | - Muhammad Saqlain Mustafa
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Brandon Luke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Aashish Kumar
- Department of Neurosurgery, Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75010, Pakistan
| | - Burhanuddin Sohail Rangwala
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Muhammad Abdullah
- Department of Neurosurgery, Rai Medical College, Lahore Road, Sargodha City, 40100, Punjab, Pakistan
| | - Syed Muhammad Sinaan Ali
- Department of Neurosurgery, Liaquat National Hospital and Medical College, National Stadium Rd, Karachi, 74800, Pakistan
| | - Javed Iqbal
- Department of Neurosurgery, King Edward Medical University, Lahore, Pakistan
| | - Abdul Haseeb
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| |
Collapse
|
14
|
Mannella FC, Faedo F, Fumagalli M, Norata GD, Zaed I, Servadei F. Long-Term Follow-Up of Custom-Made Porous Hydroxyapatite Cranioplasties: Analysis of Infections in Adult and Pediatric Patients. J Clin Med 2024; 13:1133. [PMID: 38398446 PMCID: PMC10888657 DOI: 10.3390/jcm13041133] [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: 01/26/2024] [Revised: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024] Open
Abstract
In neurosurgery, cranioplasty (CP) stands as a pivotal surgical intervention, particularly following head trauma or various neurosurgical interventions. This study scrutinizes the intricacies of CP, emphasizing its prevalence and associated complications, with a specific focus on custom-made porous hydroxyapatite (PHA) implants. The investigation spans 687 patients (with 80 patients of pediatric age, less than 14 years old) across 26 neurosurgical centers in five European countries. Methodologically, this study delves into patient characteristics, complications, and infection data through a comprehensive post-marketing on-site surveillance approach. Notably, infections emerged as the primary complication, affecting 41 patients (6% of implants) with a clear distinction in onset patterns between pediatric (with more infections, 10% versus 5.4% in adults and an earlier onset of complications) and adult populations. Out of these 41 cases, cranioplasty explantation was required in 30 patients, 4.4% of the total population. Furthermore, bifrontal decompression correlated with a significantly elevated infection risk as compared to unilateral decompression (12.5% versus 5.1%) which remains after the examination of possible confounding factors. These findings provide substantial insights into the complexities of CP, suggesting the necessity for tailored strategies in pediatric and adult cases and cautioning against bifrontal decompressions. Despite acknowledging limitations and calling for prospective studies with long term follow-up, this research advances our understanding of the use of PHA CP, guiding clinical decision-making and emphasizing the importance of customized approaches for diverse patient cohorts.
Collapse
Affiliation(s)
- Francesca Carolina Mannella
- Department of Pharmacological and Biomolecular Sciences “Rodolfo Paoletti”, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.); (G.D.N.)
| | - Francesca Faedo
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy;
| | - Marta Fumagalli
- Department of Pharmacological and Biomolecular Sciences “Rodolfo Paoletti”, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.); (G.D.N.)
| | - Giuseppe Danilo Norata
- Department of Pharmacological and Biomolecular Sciences “Rodolfo Paoletti”, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.); (G.D.N.)
| | - Ismail Zaed
- Department of Neurosurgery, Neurocenter of the Southern Switzerland, Regional Hospital of Lugano, CH-2900 Lugano, Switzerland;
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy;
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| |
Collapse
|
15
|
Habibi MA, Kobets AJ, Boskabadi AR, Mousavi Nasab M, Sobhanian P, Saber Hamishegi F, Naseri Alavi SA. A comprehensive systematic review and meta-analysis study in comparing decompressive craniectomy versus craniotomy in patients with acute subdural hematoma. Neurosurg Rev 2024; 47:77. [PMID: 38336894 PMCID: PMC10858084 DOI: 10.1007/s10143-024-02292-5] [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: 12/15/2023] [Revised: 01/06/2024] [Accepted: 01/14/2024] [Indexed: 02/12/2024]
Abstract
There are two controversial surgery methods which are traditionally used: craniotomy and decompressive craniectomy. The aim of this study was to evaluate the efficacy and complications of DC versus craniotomy for surgical management in patients with acute subdural hemorrhage (SDH) following traumatic brain injury (TBI). We conducted a comprehensive search on PubMed, Scopus, Web of Science, and Embase up to July 30, 2023, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Relevant articles were reviewed, with a focus on studies comparing decompressive craniectomy to craniotomy techniques in patients with SDH following TBI. Ten studies in 2401 patients were reviewed. A total of 1170 patients had a craniotomy, and 1231 had decompressive craniectomy. The mortality rate was not significantly different between the two groups (OR: 0.46 [95% CI: 0.42-0.5] P-value: 0.07). The rate of revision surgery was insignificantly different between the two groups (OR: 0.59 [95% CI: 0.49-0.69] P-value: 0.08). No significant difference was found between craniotomy and decompressive craniectomy regarding unilateral mydriasis (OR: 0.46 [95% CI: 0.35-0.57] P-value < 0.001). However, the craniotomy group had significantly lower rates of non-pupil reactivity (OR: 0.27 [95% CI: 0.17-0.41] P-value < 0.001) and bilateral mydriasis (OR: 0.59 [95% CI: 0.5-0.66] P-value: 0.04). There was also no significant difference in extracranial injury between the two groups, although the odds ratio of significant extracranial injury was lower in the craniotomy group (OR: 0.58 [95% CI: 0.45-0.7] P-value: 0.22). Our findings showed that non-pupil and bilateral-pupil reactivity were significantly more present in decompressive craniectomy. However, there was no significant difference between the two groups regarding mortality rate, extracranial injury, revision surgery, and one-pupil reactivity.
Collapse
Affiliation(s)
- Mohammad Amin Habibi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Clinical Research Development Center, Qom University of Medical Sciences, Qom, Iran
| | - Andrew J Kobets
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | | | - Mehdi Mousavi Nasab
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pooria Sobhanian
- Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Seyed Ahmad Naseri Alavi
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA.
| |
Collapse
|
16
|
Wijdicks EFM. Idiosyncrasies of Outcome Grading After Brain Injury: Past into the Present. Neurocrit Care 2024:10.1007/s12028-023-01918-8. [PMID: 38332335 DOI: 10.1007/s12028-023-01918-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 02/10/2024]
Affiliation(s)
- Eelco F M Wijdicks
- Neurocritical Care Services, Saint Marys Hospital, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
17
|
Sorek S, Miller A, Griepp D, Mathew V, Moawad S, Rahme R. Two-Stage Anatomic Myocutaneous Flap Dissection in Cranioplasty: Technical Nuances and Single-Surgeon Experience. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01025. [PMID: 38260933 DOI: 10.1227/ons.0000000000001063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/08/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Temporalis muscle management remains one of the most challenging aspects of cranioplasty, which accounts for considerable rates of dissection-related complications. Since 2019, the senior author has developed and consistently used a methodical, two-stage anatomic dissection technique to separate the scalp and temporalis muscle from the underlying brain. This technique is believed to facilitate dissection and minimize the risk of brain injury, while optimizing cosmetic outcomes. METHODS All patients who underwent cranioplasty between January 2019 and February 2023 were identified from a prospectively maintained database. Charts were retrospectively reviewed. Demographic, clinical, and procedural data were extracted and analyzed. RESULTS Twenty-nine patients, 20 men and 9 women with a median age of 37 years (range 17-72), were identified. Indications for craniectomy were traumatic brain injury in 18 (62.1%), hemorrhagic stroke in five (17.2%), ischemic stroke in four (13.8%), and aneurysmal subarachnoid hemorrhage in two (6.9%). Median precranioplasty modified Rankin Scale and Glasgow Coma Scale scores were 5 (range in series: 0-5) and 14 (range in series: 3-15), respectively. The median time to cranioplasty was 131 days (32-1717). Cranioplasty was technically successful in all patients, with a median operative time of 106 minutes (62-182). There were no intraoperative complications. Postoperative complications occurred in three patients (10.3%): hemorrhagic brain contusion (n = 1), meningitis (n = 1), and seizure (n = 1). Of those, one patient (3.4%) died 2 weeks after surgery from suspected pulmonary embolism. After a median follow-up of 4 months (1-44), all 28 survivors have either remained clinically stable or exhibited neurological improvement. Cosmetic results were good or excellent in 27 (96.4%) and fair in one (3.6%). CONCLUSION Two-stage anatomic dissection of the scalp and temporalis muscle during cranioplasty can maximize surgical efficiency and result in excellent outcomes. Cranioplasty should be considered a low-risk, low-complexity neurosurgical procedure. Safe and efficient management of the temporalis muscle is key.
Collapse
Affiliation(s)
- Sahar Sorek
- Division of Neurosurgery, SBH Health System, Bronx, New York, USA
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York, USA
| | - Aaron Miller
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Daniel Griepp
- Division of Neurosurgery, Ascension Providence Hospital, College of Human Medicine, Michigan State University, Southfield, Michigan, USA
| | - Vincy Mathew
- Division of Neurosurgery, SBH Health System, Bronx, New York, USA
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York, USA
| | - Stephanie Moawad
- Division of Neurosurgery, SBH Health System, Bronx, New York, USA
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York, USA
| | - Ralph Rahme
- Division of Neurosurgery, SBH Health System, Bronx, New York, USA
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York, USA
- CUNY School of Medicine, New York, New York, USA
| |
Collapse
|
18
|
Maas AIR, Menon DK. Highlights in traumatic brain injury research in 2023. Lancet Neurol 2024; 23:15-17. [PMID: 38101885 DOI: 10.1016/s1474-4422(23)00458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem 2650, Belgium; Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium.
| | - David K Menon
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| |
Collapse
|
19
|
Phillips BT, Bejar-Chapa M, Chaya BF, Chi D, Gonzalez SR, Hussein S, Marji FP, Muller J, Patel NK, Scarabosio A, Thacoor A. Spotlight in Plastic Surgery: January 2024. Plast Reconstr Surg 2024; 153:270-272. [PMID: 38127454 DOI: 10.1097/prs.0000000000011064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
|
20
|
Hossain I, Rostami E, Marklund N. The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies. Curr Opin Crit Care 2023; 29:650-658. [PMID: 37851061 PMCID: PMC10624411 DOI: 10.1097/mcc.0000000000001094] [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] [Indexed: 10/19/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours. RECENT FINDINGS Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials. SUMMARY Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.
Collapse
Affiliation(s)
- Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala
- Department of Neuroscience, Karolinska institute, Stockholm
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
21
|
Rickard F, Gale J, Williams A, Shipway D. New horizons in subdural haematoma. Age Ageing 2023; 52:afad240. [PMID: 38167695 DOI: 10.1093/ageing/afad240] [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: 06/05/2023] [Indexed: 01/05/2024] Open
Abstract
Subdural haematoma (SDH) is a common injury sustained by older people living with frailty and multimorbidity, and typically following falls from a standing height. Anticoagulant and antiplatelet use are commonly indicated in older people with SDH, but few data inform decision-making surrounding these agents in the context of intracranial bleeding. Opposing risks of rebleeding and thrombosis must therefore be weighed judiciously. Decision-making can be complex and requires detailed awareness of the epidemiology to ensure the safest course of action is selected for each patient. Outcomes of surgical decompression in acute SDH are very poor in older people. However, burr hole drainage can be safe and effective in older adults with symptomatic chronic SDH (cSDH). Such patients need careful assessment to ensure symptoms arise from cSDH and not from coexisting medical pathology. Furthermore, the emerging treatment of middle meningeal artery embolisation offers a well-tolerated, minimally invasive intervention which may reduce the risks of rebleeding in older adults. Nonetheless, UK SDH management is heterogenous, and no accepted UK or European guidelines exist at present. Further randomised trial evidence is required to move away from clinical practice based on historic observational data.
Collapse
Affiliation(s)
- Frances Rickard
- Consultant Geriatrician, Geriatric Major Trauma, North Bristol NHS Trust, Bristol, UK
| | - John Gale
- Clinical Fellow in Geriatric Major Trauma, North Bristol NHS Trust, Bristol, UK
| | - Adam Williams
- Consultant Neurosurgeon, Department of Neurosurgery, North Bristol NHS Trust, Bristol, UK
| | - David Shipway
- Consultant Geriatrician, Geriatric Major Trauma, North Bristol NHS Trust, Bristol, UK
- Honorary Senior Clinical Lecturer, University of Bristol, Bristol, UK
| |
Collapse
|
22
|
Beucler N. Decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma. Neurochirurgie 2023; 69:101490. [PMID: 37713942 DOI: 10.1016/j.neuchi.2023.101490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 09/17/2023]
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, French Military Health Service Academy, 1 place Alphonse Laveran, 75230 PAris Cedex 5, France.
| |
Collapse
|
23
|
Figaji A. An update on pediatric traumatic brain injury. Childs Nerv Syst 2023; 39:3071-3081. [PMID: 37801113 PMCID: PMC10643295 DOI: 10.1007/s00381-023-06173-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) remains the commonest neurological and neurosurgical cause of death and survivor disability among children and young adults. This review summarizes some of the important recent publications that have added to our understanding of the condition and advanced clinical practice. METHODS Targeted review of the literature on various aspects of paediatric TBI over the last 5 years. RESULTS Recent literature has provided new insights into the burden of paediatric TBI and patient outcome across geographical divides and the severity spectrum. Although CT scans remain a standard, rapid sequence MRI without sedation has been increasingly used in the frontline. Advanced MRI sequences are also being used to better understand pathology and to improve prognostication. Various initiatives in paediatric and adult TBI have contributed regionally and internationally to harmonising research efforts in mild and severe TBI. Emerging data on advanced brain monitoring from paediatric studies and extrapolated from adult studies continues to slowly advance our understanding of its role. There has been growing interest in non-invasive monitoring, although the clinical applications remain somewhat unclear. Contributions of the first large scale comparative effectiveness trial have advanced knowledge, especially for the use of hyperosmolar therapies and cerebrospinal fluid drainage in severe paediatric TBI. Finally, the growth of large and even global networks is a welcome development that addresses the limitations of small sample size and generalizability typical of single-centre studies. CONCLUSION Publications in recent years have contributed iteratively to progress in understanding paediatric TBI and how best to manage patients.
Collapse
Affiliation(s)
- Anthony Figaji
- Division of Neurosurgery and Neurosciences Institute, University of Cape Town, Cape Town, South Africa.
| |
Collapse
|
24
|
Beucler N. Letter to the Editor Regarding "Decompressive Hemicraniectomies as a Damage Control Approach for Multilobar Firearm Projectile Injuries: A Single-Center Experience". World Neurosurg 2023; 179:239-241. [PMID: 38059592 DOI: 10.1016/j.wneu.2023.05.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France; Ecole du Val-de-Grâce, French Military French Health Service Academy, Paris, France.
| |
Collapse
|
25
|
Pinggera D, Geiger P, Thomé C. [Traumatic brain injury]. DER NERVENARZT 2023; 94:960-972. [PMID: 37676293 PMCID: PMC10575816 DOI: 10.1007/s00115-023-01546-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
Traumatic brain injury (TBI) describes parenchymal brain damage caused by external forces to the head. It has a massive personal and socioeconomic impact, as it is a disease with high morbidity and mortality. Both young and old people are affected, as a result of traffic or sports accidents as well as due to falls at home. The term TBI encompasses various clinical pictures, differing considerably in cause, prognosis and therapy. What they all have in common is the pathophysiological cascade that develops immediately after the initial trauma and which can persist for several days and weeks. In this phase, medical treatment, whether surgical or pharmacological, attempts to reduce the consequences of the primary damage. The aim is to maintain adequate cerebral perfusion pressure and to reduce intracranial pressure.
Collapse
Affiliation(s)
- D Pinggera
- Universitätsklinik für Neurochirurgie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - P Geiger
- Universitätsklinik für Neurochirurgie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - C Thomé
- Universitätsklinik für Neurochirurgie, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| |
Collapse
|
26
|
van Essen TA, van Erp IA, Lingsma HF, Pisică D, Yue JK, Singh RD, van Dijck JT, Volovici V, Younsi A, Kolias A, Peppel LD, Heijenbrok-Kal M, Ribbers GM, Menon DK, Hutchinson PJ, Manley GT, Depreitere B, Steyerberg EW, Maas AI, de Ruiter GC, Peul WC. Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study. EClinicalMedicine 2023; 63:102161. [PMID: 37600483 PMCID: PMC10432786 DOI: 10.1016/j.eclinm.2023.102161] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023] Open
Abstract
Background Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. Methods We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Findings Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7-1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n = 200]). Interpretation We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Funding Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.
Collapse
Affiliation(s)
- Thomas A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- Department of Surgery, Division of Neurosurgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Inge A.M. van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Hester F. Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Dana Pisică
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - John K. Yue
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Ranjit D. Singh
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Jeroen T.J.M. van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Alexander Younsi
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Lianne D. Peppel
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Majanka Heijenbrok-Kal
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Gerard M. Ribbers
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J.A. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Godard C.W. de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Wilco C. Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| |
Collapse
|
27
|
Chesnut RM, Bonow RH. Craniectomy or Craniotomy for Acute Subdural Hematoma. N Engl J Med 2023; 389:862. [PMID: 37646686 DOI: 10.1056/nejmc2308428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|
28
|
Pingue V, Franciotta D. Functional outcome in patients with traumatic or hemorrhagic brain injuries undergoing decompressive craniectomy versus craniotomy and 6-month rehabilitation. Sci Rep 2023; 13:10624. [PMID: 37391549 PMCID: PMC10313652 DOI: 10.1038/s41598-023-37747-0] [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: 02/06/2023] [Accepted: 06/27/2023] [Indexed: 07/02/2023] Open
Abstract
Decompressive craniectomy (DC) and craniotomy (CT) to treat increased intracranial pressure after brain injury are common but controversial choices in clinical practice. Studying a large cohort of patients with traumatic brain injury (TBI) and hemorrhagic stroke (HS) on rehabilitation pathways, we aimed to determine the impact of DC and CT on functional outcome/mortality, and on seizures occurrence. This observational retrospective study included patients with either TBI, or HS, who underwent DC or CT, consecutively admitted to our unit for 6-month neurorehabilitation programs between January 1, 2009 and December 31, 2018. Neurological status using Glasgow Coma Scale (GCS), and rehabilitation outcome with Functional Independence Measure, both assessed at baseline and on discharge, post-DC cranioplasty, prophylactic antiepileptic drug use, occurrence of early/late seizures, infectious complications, and death during hospitalization were evaluated and analyzed with linear and logistic regression models. Among 278 patients, DC was performed in 98 (66.2%) with HS, and in 98 (75.4%) with TBI, whilst CT in 50 (33.8%) with HS, and in 32 (24.6%) with TBI. On admission, GCS scores were lower in patients treated with CT than in those with DC (HS, p = 0.016; TBI, p = 0.024). Severity of brain injury and older age were the main factors affecting functional outcome, without between-group differences, but DC associated with worse functional outcome, independently from severity or type of brain injury. Unprovoked seizures occurred post-DC cranioplasty more frequently after HS (OR = 5.142, 95% CI 1.026-25.784, p = 0.047). DC and CT shared similar risk of mortality, which associated with sepsis (OR = 16.846, 95% CI 5.663-50.109, p < 0.0001), or acute symptomatic seizures (OR = 4.282, 95% CI 1.276-14.370, p = 0.019), independently from the neurosurgery procedures. Among CT and DC, the latter neurosurgical procedure is at major risk of worse functional outcome in patients with mild-to-severe TBI, or HS undergoing an intensive rehabilitation program. Complications with sepsis or acute symptomatic seizures increase the risk of death.
Collapse
Affiliation(s)
- Valeria Pingue
- Neurorehabilitation and Spinal Unit, Istituti Clinici Scientifici Maugeri IRCCS, Via Maugeri 4, 27100, Pavia, Italy.
| | | |
Collapse
|
29
|
Gopinath S. Traumatic Acute Subdural Hematoma - Should the Bone Flap Be Removed or Replaced? N Engl J Med 2023. [PMID: 37092779 DOI: 10.1056/nejme2302936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Affiliation(s)
- Shankar Gopinath
- From the Department of Neurosurgery, Baylor College of Medicine, Houston
| |
Collapse
|