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He H, Liu J, Li C, Guo Y, Liang K, Du J, Xue J, Liang Y, Chen P, Liu L, Cui M, Wang J, Liu Y, Tian S, Deng Y. Predicting Hematoma Expansion and Prognosis in Cerebral Contusions: A Radiomics-Clinical Approach. J Neurotrauma 2024; 41:1337-1352. [PMID: 38326935 DOI: 10.1089/neu.2023.0410] [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: 02/09/2024] Open
Abstract
Hemorrhagic progression of contusion (HPC) often occurs early in cerebral contusions (CC) patients, significantly impacting their prognosis. It is vital to promptly assess HPC and predict outcomes for effective tailored interventions, thereby enhancing prognosis in CC patients. We utilized the Attention-3DUNet neural network to semi-automatically segment hematomas from computed tomography (CT) images of 452 CC patients, incorporating 695 hematomas. Subsequently, 1502 radiomic features were extracted from 358 hematomas in 261 patients. After a selection process, these features were used to calculate the radiomic signature (Radscore). The Radscore, along with clinical features such as medical history, physical examinations, laboratory results, and radiological findings, was employed to develop predictive models. For prognosis (discharge Glasgow Outcome Scale score), radiomic features of each hematoma were augmented and fused for correlation. We employed various machine learning methodologies to create both a combined model, integrating radiomics and clinical features, and a clinical-only model. Nomograms based on logistic regression were constructed to visually represent the predictive procedure, and external validation was performed on 170 patients from three additional centers. The results showed that for HPC, the combined model, incorporating hemoglobin levels, Rotterdam CT score of 3, multi-hematoma fuzzy sign, concurrent subdural hemorrhage, international normalized ratio, and Radscore, achieved area under the receiver operating characteristic curve (AUC) values of 0.848 and 0.836 in the test and external validation cohorts, respectively. The clinical model predicting prognosis, utilizing age, Abbreviated Injury Scale for the head, Glasgow Coma Scale Motor component, Glasgow Coma Scale Verbal component, albumin, and Radscore, attained AUC values of 0.846 and 0.803 in the test and external validation cohorts, respectively. Selected radiomic features indicated that irregularly shaped and highly heterogeneous hematomas increased the likelihood of HPC, while larger weighted axial lengths and lower densities of hematomas were associated with a higher risk of poor prognosis. Predictive models that combine radiomic and clinical features exhibit robust performance in forecasting HPC and the risk of poor prognosis in CC patients. Radiomic features complement clinical features in predicting HPC, although their ability to enhance the predictive accuracy of the clinical model for adverse prognosis is limited.
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Affiliation(s)
- Haoyue He
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
- Bioengineering College, Chongqing University, Chongqing, China
| | - Jinxin Liu
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
- School of Medicine, Chongqing University, Chongqing, China
| | - Chuanming Li
- Medical Imaging Department, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
| | - Yi Guo
- Medical Imaging Department, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
| | - Kaixin Liang
- Department of Neurosurgery, Yubei District Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Jun Du
- Department of Neurosurgery, Chongqing Qianjiang Central Hospital, Chongqing University Qianjiang Hospital, Chongqing, China
| | - Jun Xue
- Department of Neurosurgery, Bishan Hospital of Chongqing, Bishan Hospital of Chongqing Medical University, Chongqing, China
| | - Yidan Liang
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
| | - Peng Chen
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
| | - Liu Liu
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
| | - Min Cui
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
| | - Jia Wang
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
| | - Ye Liu
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
- School of Medicine, Chongqing University, Chongqing, China
| | - Shanshan Tian
- Department of Prehospital Emergency, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
| | - Yongbing Deng
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, China
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Wu B, Zhang J, Chen J, Sun X, Tan D. Establishment of a model to predict mortality after decompression craniotomy for traumatic brain injury. Brain Behav 2024; 14:e3492. [PMID: 38641890 PMCID: PMC11031634 DOI: 10.1002/brb3.3492] [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: 06/04/2023] [Revised: 02/24/2024] [Accepted: 04/03/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND The mortality rate of patients with traumatic brain injury (TBI) is still high even while undergoing decompressive craniectomy (DC), and the expensive treatment costs bring huge economic burden to the families of patients. OBJECTIVE The aim of this study was to identify preoperative indicators that influence patient outcomes and to develop a risk model for predicting patient mortality by a retrospective analysis of TBI patients undergoing DC. METHODS A total of 288 TBI patients treated with DC, admitted to the First Affiliated Hospital of Shantou University Medical School from August 2015 to April 2021, were used for univariate and multivariate logistic regression analysis to determine the risk factors for death after DC in TBI patients. We also built a risk model for the identified risk factors and conducted internal verification and model evaluation. RESULTS Univariate and multivariate logistic regression analysis identified four risk factors: Glasgow Coma Scale, age, activated partial thrombin time, and mean CT value of the superior sagittal sinus. These risk factors can be obtained before DC. In addition, we also developed a 3-month mortality risk model and conducted a bootstrap 1000 resampling internal validation, with C-indices of 0.852 and 0.845, respectively. CONCLUSIONS We developed a risk model that has clinical significance for the early identification of patients who will still die after DC. Interestingly, we also identified a new early risk factor for TBI patients after DC, that is, preoperative mean CT value of the superior sagittal sinus (p < .05).
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Affiliation(s)
- Birui Wu
- Department of NeurosurgeryGuangdong Sanjiu Brain HospitalGuangzhouGuangdongChina
| | - Juntao Zhang
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeShantouGuangdongChina
| | - Junchen Chen
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeShantouGuangdongChina
| | - Xibo Sun
- Department of NeurosurgeryGuangdong Sanjiu Brain HospitalGuangzhouGuangdongChina
| | - Dianhui Tan
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeShantouGuangdongChina
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Park JH, Jung IH, Yun JH. The Efficacy of Traumatic Brain Injury Treatment by Neurotrauma Specialists. Korean J Neurotrauma 2024; 20:8-16. [PMID: 38576504 PMCID: PMC10990690 DOI: 10.13004/kjnt.2024.20.e12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
Objective Since the establishment of Regional Trauma Centers (RTCs) in Korea, significant efforts have been made to improve the quality of care for patients with trauma. Simultaneously, the Department of Neurosurgery assigned neurotrauma specialists to RTCs to provide specialized care to patients with traumatic brain injury (TBI). In this study, we sought to determine whether neurotrauma specialists, compared to general neurosurgeons, could make a significant difference in treatment outcomes of patients with TBI. Methods In total, 156 patients with acute TBI who required decompression were included. We reviewed their records and compared the characteristics, outcomes, and prognosis of those who received surgical treatment from either neurotrauma specialists or general neurosurgeons at our institution. Results A significant difference was observed between treatment by trauma neurosurgery specialists and general neurosurgeons in time to surgery, with trauma specialists experiencing shorter surgical delays. However, no significant differences existed in mortality rates or Extended Glasgow Outcome Scale scores. Univariate and multivariable regression analyses revealed that lower Glasgow Coma Scale scores, an abnormal pupil reflex, larger transfusion volume, and prolonged time from emergency room admission to surgery were associated with high mortality rates. Conclusion Neurotrauma specialists can provide prompt surgical treatment to patients with TBI compared to general neurosurgeons. Our study did not reveal a significant difference in outcomes between the two groups. However, it is clear that rapid decompression is effective in patients with impending brain herniation. Therefore, the effectiveness of neurotrauma specialists needs to be confirmed through further systematic studies.
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Affiliation(s)
- Jung Hwan Park
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - In-Ho Jung
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Jung-Ho Yun
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
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Szczygielski J, Hubertus V, Kruchten E, Müller A, Albrecht LF, Schwerdtfeger K, Oertel J. Prolonged course of brain edema and neurological recovery in a translational model of decompressive craniectomy after closed head injury in mice. Front Neurol 2023; 14:1308683. [PMID: 38053795 PMCID: PMC10694459 DOI: 10.3389/fneur.2023.1308683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/01/2023] [Indexed: 12/07/2023] Open
Abstract
Background The use of decompressive craniectomy in traumatic brain injury (TBI) remains a matter of debate. According to the DECRA trial, craniectomy may have a negative impact on functional outcome, while the RescueICP trial revealed a positive effect of surgical decompression, which is evolving over time. This ambivalence of craniectomy has not been studied extensively in controlled laboratory experiments. Objective The goal of the current study was to investigate the prolonged effects of decompressive craniectomy (both positive and negative) in an animal model. Methods Male mice were assigned to the following groups: sham, decompressive craniectomy, TBI and TBI followed by craniectomy. The analysis of functional outcome was performed at time points 3d, 7d, 14d and 28d post trauma according to the Neurological Severity Score and Beam Balance Score. At the same time points, magnetic resonance imaging was performed, and brain edema was analyzed. Results Animals subjected to both trauma and craniectomy presented the exacerbation of the neurological impairment that was apparent mostly in the early course (up to 7d) after injury. Decompressive craniectomy also caused a significant increase in brain edema volume (initially cytotoxic with a secondary shift to vasogenic edema and gliosis). Notably, delayed edema plus gliosis appeared also after decompression even without preceding trauma. Conclusion In prolonged outcomes, craniectomy applied after closed head injury in mice aggravates posttraumatic brain edema, leading to additional functional impairment. This effect is, however, transient. Treatment options that reduce brain swelling after decompression may accelerate neurological recovery and should be explored in future experiments.
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Affiliation(s)
- Jacek Szczygielski
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Instutute of Neuropathology, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Institute of Medical Sciences, University of Rzeszów, Rzeszow, Poland
| | - Vanessa Hubertus
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Department of Neurosurgery, Charité University Medicine, Berlin, Germany
- Berlin Institute of Health at Charité, Berlin, Germany
| | - Eduard Kruchten
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Institute of Interventional and Diagnostic Radiology, Karlsruhe, Germany
| | - Andreas Müller
- Department of Radiology, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Lisa Franziska Albrecht
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Karsten Schwerdtfeger
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
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Biroli A, Bignotti V, Biroli P, Buffoli B, Rasulo FA, Doglietto F, Rezzani R, Fiorindi A, Fontanella MM, Belotti F. Hinge craniotomy versus standard decompressive hemicraniectomy: an experimental preclinical comparative study. Acta Neurochir (Wien) 2023; 165:2365-2375. [PMID: 37452903 DOI: 10.1007/s00701-023-05715-2] [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: 03/05/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Decompressive craniectomy (DC) is the most common surgical procedure to manage increased intracranial pressure (ICP). Hinge craniotomy (HC), which consists of fixing the bone operculum with a pivot, is an alternative method conceived to avoid some DC-related complications; nonetheless, it is debated whether it can provide enough volume expansion. In this study, we aimed to analyze the volume and ICP obtained with HC using an experimental cadaver-based preclinical model and compare the results to baseline and DC. METHODS Baseline conditions, HC, and DC were compared on both sides of five anatomical specimens. Volume and ICP values were measured with a custom-made system. Local polynomial regression was used to investigate volume differences. RESULTS The area of the bone opercula resulting from measurements was 115.55 cm2; the mean supratentorial volume was 955 mL. HC led to intermediate results compared to baseline and DC. At an ICP of 50 mmHg, HC offers 130 mL extra space but 172 mL less than a DC. Based on local polynomial regression, the mean volume difference between HC and the standard craniotomy was 10%; 14% between DC and HC; both are higher than the volume of brain herniation reported in the literature in the clinical setting. The volume leading to an ICP of 50 mmHg at baseline was less than the volume needed to reach an ICP of 20 mmHg after HC (10.05% and 14.95% from baseline, respectively). CONCLUSIONS These data confirm the efficacy of HC in providing sufficient volume expansion. HC is a valid intermediate alternative in case of potentially evolutionary lesions and non-massive edema, especially in developing countries.
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Affiliation(s)
- Antonio Biroli
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Valentina Bignotti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Pietro Biroli
- Department of Economics, University of Bologna, Via Zamboni 33, 40126, Bologna, Italy
| | - Barbara Buffoli
- Section of Anatomy and Pathophysiology, Department of Clinical and Experimental Sciences, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Francesco A Rasulo
- Unit of Anesthesia, Critical Care and Emergency, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Francesco Doglietto
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168, Rome, Italy
- Unit of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Rita Rezzani
- Section of Anatomy and Pathophysiology, Department of Clinical and Experimental Sciences, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Alessandro Fiorindi
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Francesco Belotti
- Unit of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy.
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Ziechmann R, Pathak SM, Welch J, Villanueva P. Delayed Traumatic Intracerebral Hematoma: A Pathophysiological Classification and Literature Review. Cureus 2023; 15:e42987. [PMID: 37671206 PMCID: PMC10476546 DOI: 10.7759/cureus.42987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/07/2023] Open
Abstract
Delayed traumatic intracerebral hematoma (DTICH) is a relatively common occurrence after a traumatic brain injury (TBI). Several case series have been performed to study DTICH, many of which offer different definitions of DTICH. Some definitions involve a delayed progression of an existing hemorrhage, and others involve a de novo intracerebral hematoma that was not evident on the initial trauma evaluation. We propose a classification system for DTICH that accounts for the subtleties in the clinical manifestation and pathophysiology of the different types of DTICH, with the ultimate goal of providing strategies to prevent and manage DTICH. Based on the senior author's clinical experience, we generated a classification system for DTICH, and each type of DTICH was illustrated with a case. We defined type 1A (case 1A), the classic presentation of DTICH as predominantly characterized in the literature, as an intracerebral hematoma unseen on initial computed tomography imaging that typically develops five days to one week following blunt or penetrating head trauma. We defined type 1B (case 1B) as a hematoma that forms after at least one week following trauma in areas of the brain initially hemorrhage-free. We defined type 2 (case 2) as a hematoma that develops rapidly following a surgical evacuation of a different hematoma. We defined type 3 (case 3) as a hematoma that develops after a traumatic head injury in areas of non-hemorrhagic contusion, usually frontal or temporal. A literature review was performed using select terms on PubMed to find articles related to DTICH, excluding articles describing DTICH from an underlying vascular injury. After performing the literature review and screening articles by title and/or abstract, a total of 79 articles were found to meet the inclusion and exclusion criteria. We recorded which type of DTICH from our classification system best correlated with the articles in our literature review. Taken together with results from the literature, the proposed classification system is based on the senior author's clinical experience. Overall, DTICH is a relatively common occurrence after head trauma, and our pathophysiologic classification has the potential to help outline future studies to recognize and prevent the development of DTICH.
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Affiliation(s)
| | - Sami M Pathak
- Neurosurgery, Temple University Hospital, Philadelphia, USA
| | - Jonathan Welch
- Neurosurgery, Temple University Hospital, Philadelphia, USA
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Sengupta SK, Sundervadhanan S, Rappai TJ, Sudumbrekar S, Gorthi SP, Verma SK. Step Ladder Expansive Cranioplasty: A Novel Perspective in Cranial Volume Augmentation Surgery. Asian J Neurosurg 2023; 18:414-419. [PMID: 37397047 PMCID: PMC10313430 DOI: 10.1055/s-0043-1768571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Background In face of a refractory raised intracranial pressure (ICP), surgeons most commonly resort to decompressive craniectomy (DC). Procedure leaves an unprotected brain underlying the craniectomy defect and Monro-Kellie doctrine: disrupted. Different variants of hinge craniotomies (HC) have been used with clinical outcomes comparable to DC as single stage alternatives. However, both DC and every variant of HC have a limit to the achievable volume augmentation and all invariably cause a compression of the cerebral cortex and its vasculature at the craniotomy site. We believe both these limitations adversely affect the outcome. Methods A team of neuroscientists in Indian Armed Forces Medical Services has been working for the last 9 years toward developing a novel surgical technique that can mitigate both these drawbacks. Desired procedure should take the centripetal pressure exerted by the combination of the tensile strength of the scalp (with or, without an underlying bone flap) and atmospheric pressure off the brain surface while achieving an assured augmentation of intracranial volume that can be optimized on a case-to-case basis. We call it a "step ladder expansive cranioplasty." Results The distance of the parietal eminence was found to have increased by 10.2 mm on the operated side after expansive cranioplasty. Conclusion From drawing board to bedside, we have made some progress toward our goal, but it is still far away from completion. More studies are required to fill in the gaps in our knowledge necessary to optimize the various parameters of the surgery. Procedure has promise to be of special role in in war and disaster scenarios.
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Affiliation(s)
- Sudip Kumar Sengupta
- Department of Neurosurgery, Command Hospital (Southern Command), Pune, Maharashtra, India
| | | | - Tony J. Rappai
- Department of Surgery, Military Hospital, Gwalior, Madhya Pradesh, India
| | - S.M. Sudumbrekar
- Department of Neurosurgery, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Sankar Prasad Gorthi
- Department of Neurosurgery, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
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Wang R, Yang DX, Ding J, Guo Y, Ding WH, Tian HL, Yuan F. Classification, risk factors, and outcomes of patients with progressive hemorrhagic injury after traumatic brain injury. BMC Neurol 2023; 23:68. [PMID: 36782124 PMCID: PMC9926699 DOI: 10.1186/s12883-023-03112-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND According to the pathoanatomic classification system, progressive hemorrhagic injury (PHI) can be categorized into progressive intraparenchymal contusion or hematoma (pIPCH), epidural hematoma (pEDH), subdural hematoma (pSDH), and traumatic subarachnoid hemorrhage (ptSAH). The clinical features of each type differ greatly. The objective of this study was to determine the predictors, clinical management, and outcomes of PHI according to this classification. METHODS Multivariate logistic regression analysis was used to identify independent risk factors for PHI and each subgroup. Patients with IPCH or EDH were selected for subgroup propensity score matching (PSM) to exclude confounding factors before evaluating the association of hematoma progression with the outcomes by classification. RESULTS In the present cohort of 419 patients, 123 (29.4%) demonstrated PHI by serial CT scan. Of them, progressive ICPH (58.5%) was the most common type, followed by pEDH (28.5%), pSDH (9.8%), and ptSAH (3.2%). Old age (≥ 60 years), lower motor Glasgow Coma Scale score, larger primary lesion volume, and higher level of D-dimer were independent risk factors related to PHI. These factors were also independent predictors for pIPCH, but not for pEDH. The time to first CT scan and presence of skull linear fracture were robust risk factors for pEDH. After PSM, the 6-month mortality and unfavorable survival rates were significantly higher in the pIPCH group than the non-pIPCH group (24.2% vs. 1.8% and 12.1% vs. 7.3%, respectively, p < 0.001), but not significantly different between the pEDH group and the non-pEDH group. CONCLUSIONS Understanding the specific patterns of PHI according to its classification can help early recognition and suggest targeted prevention or treatment strategies to improve patients' neurological outcomes.
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Affiliation(s)
- Ren Wang
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dian-Xu Yang
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Ding
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Guo
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wan-Hai Ding
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Heng-Li Tian
- Department of Neurosurgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Fang Yuan
- Department of Neurosurgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Scurfield AK, Wilson MD, Gurkoff G, Martin R, Shahlaie K. Identification of Demographic and Clinical Prognostic Factors in Traumatic Intraventricular Hemorrhage. Neurocrit Care 2023; 38:149-157. [PMID: 36050537 PMCID: PMC9957945 DOI: 10.1007/s12028-022-01587-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/08/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The presence of traumatic intraventricular hemorrhage (tIVH) following traumatic brain injury (TBI) is associated with worse neurological outcome. The mechanisms by which patients with tIVH have worse outcome are not fully understood and research is ongoing, but foundational studies that explore prognostic factors within tIVH populations are also lacking. This study aimed to further identify and characterize demographic and clinical variables within a subset of patients with TBI and tIVH that may be implicated in tIVH outcome. METHODS In this observational study, we reviewed a large prospective TBI database to determine variables present on admission that predicted neurological outcome 6 months after injury. A review of 7,129 patients revealed 211 patients with tIVH on admission and 6-month outcome data. Hypothesized risk factors were tested in univariate analyses with significant variables (p < 0.05) included in logistic and linear regression models. Following the addition of either the Rotterdam computed tomography or Glasgow Coma Scale (GCS) score, we employed a backward selection process to determine significant variables in each multivariate model. RESULTS Our study found that that hypotension (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.13-0.94, p = 0.04) and the hemoglobin level (OR = 1.33, 95% CI = 1.09-1.63, p = 0.006) were significant predictors in the Rotterdam model, whereas only the hemoglobin level (OR = 1.29, 95% CI = 1.06-1.56, p = 0.01) was a significant predictor in the GCS model. CONCLUSIONS This study represents one of the largest investigations into prognostic factors for patients with tIVH and demonstrates that admission hemoglobin level and hypotension are associated with outcomes in this patient population. These findings add value to established prognostic scales, could inform future predictive modeling studies, and may provide potential direction in early medical management of patients with tIVH.
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Affiliation(s)
- Abby K Scurfield
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, 830 Orange Street, New Haven, CT, 06511, USA
| | - Machelle D Wilson
- Division of Biostatistics, Department of Public Health Sciences, Davis Clinical and Translational Science Center, University of California, 2921 Stockton Blvd., Suite 1400, Sacramento, CA, 95817, USA
| | - Gene Gurkoff
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
| | - Ryan Martin
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
- Department of Neurology, University of California, 4860 Y Street, Suite 3740,, Davis, Sacramento, CA, USA
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA.
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Postoperative Hematoma Expansion in Patients Undergoing Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage. Brain Sci 2022; 12:brainsci12101298. [PMID: 36291232 PMCID: PMC9599268 DOI: 10.3390/brainsci12101298] [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: 08/15/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: The aim of the study was to analyze risk factors for hematoma expansion (HE) in patients undergoing decompressive hemicraniectomy (DC) in patients with elevated intracranial pressure due to spontaneous intracerebral hematoma (ICH). Methods: We retrospectively evaluated 72 patients with spontaneous ICH who underwent DC at our institution. We compared the pre- and postoperative volumes of ICH and divided the patients into two groups: first, patients with postoperative HE > 6 cm3 (group 1), and second, patients without HE (group 2). Additionally, we screened the medical history for anticoagulant and antiplatelet medication (AC/AP), bleeding-related comorbidities, age, admission Glasgow coma scale and laboratory parameters. Results: The rate of AC/AP medication was higher in group 1 versus group 2 (15/16 vs. 5/38, p < 0.00001), and patients were significantly older in group 1 versus group 2 (65.1 ± 16.2 years vs. 54.4 ± 14.3 years, p = 0.02). Furthermore, preoperative laboratory tests showed lower rates of hematocrit (34.1 ± 5.4% vs. 38.1 ± 5.1%, p = 0.01) and hemoglobin (11.5 ± 1.6 g/dL vs. 13.13 ± 1.8 g/dL, p = 0.0028) in group 1 versus group 2. In multivariate analysis, the history of AC/AP medication was the only independent predictor of HE (p < 0.0001, OR 0.015, CI 95% 0.001−0.153). Conclusion: We presented a comprehensive evaluation of risk factors for hematoma epansion by patients undergoing DC due to ICH.
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Vychopen M, Schneider M, Borger V, Schuss P, Behning C, Vatter H, Güresir E. Complete hemispheric exposure vs. superior sagittal sinus sparing craniectomy: incidence of shear-bleeding and shunt-dependency. Eur J Trauma Emerg Surg 2022; 48:2449-2457. [PMID: 34605961 PMCID: PMC9192399 DOI: 10.1007/s00068-021-01789-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Decompressive hemicraniectomy (DC) has been established as a standard therapeutical procedure for raised intracranial pressure. However, the size of the DC remains unspecified. The aim of this study was to analyze size related complications following DC. METHODS Between 2013 and 2019, 306 patients underwent DC for elevated intracranial pressure at author´s institution. Anteroposterior and craniocaudal DC size was measured according to the postoperative CT scans. Patients were divided into two groups with (1) exposed superior sagittal sinus (SE) and (2) without superior sagittal sinus exposure (SC). DC related complications e.g. shear-bleeding at the margins of craniectomy and secondary hydrocephalus were evaluated and compared. RESULTS Craniectomy size according to anteroposterior diameter and surface was larger in the SE group; 14.1 ± 1 cm vs. 13.7 ± 1.2 cm, p = 0.003, resp. 222.5 ± 40 cm2 vs. 182.7 ± 36.9 cm2, p < 0.0001. The SE group had significantly lower rates of shear-bleeding: 20/176 patients; (11%), compared to patients of the SC group; 36/130 patients (27%), p = 0.0003, OR 2.9, 95% CI 1.6-5.5. There was no significant difference in the incidence of shunt-dependent hydrocephalus; 19/130 patients (14.6%) vs. 24/176 patients (13.6%), p = 0.9. CONCLUSIONS Complete hemispheric exposure in terms of DC with SE was associated with significantly lower levels of iatrogenic shear-bleedings compared to a SC-surgical regime. Although we did not find significant outcome difference, our findings suggest aggressive craniectomy regimes including SE to constitute the surgical treatment strategy of choice for malignant intracranial pressure.
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Affiliation(s)
- Martin Vychopen
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Charlotte Behning
- Department of Medical Biometry, Informatics and Epidemiology, Universität Bonn, Institut für Medizinische Biometrie, Informatik und Epidemiologie (IMBIE), Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
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Presenting Step-Ladder Expansive Cranioplasty as the Next Step After Decompressive Hemicraniectomy: It Is Different! ARCHIVES OF NEUROSCIENCE 2022. [DOI: 10.5812/ans.117417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Context: Decompressive hemicraniectomy (DC) is the final surgical remedy for refractory raised intracranial pressure (ICP). Even with years of experience and profound refination of technique, the procedure has less rewarding results in traumatic brain injury (TBI). Besides, arrangements for bone flap preservation and the necessity of follow-up surgery in the form of cranioplasty bring in unavoidable monetary and logistic burdens to the patients. Step-ladder expansive cranioplasty was conceptualized as an alternative to achieve adequate intracranial volume expansion to help normalize ICP, with immediate reinstitution of the Monro-Kellie doctrine. It is also expected to prevent cerebral cortical pressure injury to the cortex underlying the craniectomy defect. The evolution of this concept, as worked out on different models, the surgical technique, and our experience with this technique are discussed in this article. Evidence Acquisition: Multiple research projects undertaken by our team to build up the concept and acquire data necessary to plan the surgical procedure have been published over last eight years. This review article attempts to evaluate the existing knowledge and our clinical experience so far. Results: Step-ladder expansive cranioplasty allows an assured centrifugal displacement of the inner table and underlying dural bag at craniotomy site by at least 9 mm, thereby achieving a minimum volume expansion of 120 cc. Both of these parameters can be increased as desired, if considered necessary by the surgeon. Conclusions: Step-ladder expansive cranioplasty offers an alternative that takes the centripetal pressure exerted by the combination of the tensile strength of the scalp and atmospheric pressure off the brain surface while achieving an assured augmentation of intracranial volume that can be optimized on a case-to-case basis, based on our future understanding of the subject. While it can be a single-stage surgery for those satisfied with the cosmesis, a revision cranioplasty (if required) will be easier, cheaper, and cosmetically superior to achieving cover over a craniotomy defect routinely done after DC.
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Guo Z, Ding W, Cao D, Chen Y, Chen J. Decompressive Craniectomy vs. Craniotomy Only for Traumatic Brain Injury: A Propensity-Matched Study of Long-Term Outcomes in Neuropsychology. Front Neurol 2022; 13:813140. [PMID: 35350401 PMCID: PMC8957787 DOI: 10.3389/fneur.2022.813140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/01/2022] [Indexed: 01/23/2023] Open
Abstract
Background Both decompressive craniectomy (DC) and craniotomy only (CO) are commonly performed to treat patients with traumatic brain injury (TBI) by evacuation of intracranial hemorrhage (ICH) and control intracranial pressure (ICP). The outcomes of these two procedures have been well-studied; however, most research studies have focused on physical functions. The purpose of our study is to assess long-term outcomes in neuropsychology after DC or CO in TBI patients. Methods Information was collected from patients with TBI who had undergone DC or CO and were then in the postoperative stable phase (6–24 months after injury). Propensity scoring matched the patients in a 1:1 ratio for demographics, cause of injury, TBI subtype, TBI severity, computed tomography (CT) findings, surgery side, and interval from TBI. We used Wechsler Adult Intelligence Scale-Chinese Revision (WAIS-RC), Wechsler Memory Scale-Chinese Revision (WMS-RC), Physical Self-maintenance Scale (PSMS), Instrumental Activities of Daily Living Scale (IADL), and Glasgow Outcome Scale-Extended (GOSE) to measure the long-term outcomes in TBI patients, especially in neuropsychology. Results There were 120 TBI patients included in our study. After matching, 74 patients were paired into the DC group (n = 37) and the CO group (n = 37). There were no differences in the gender (P = 1.000), age at injury (P = 0.268), marital status (P = 0.744), pre-injury employment (P = 0.711), comorbidities (P = 1.000), education level (P = 0.969), cause of injury (P = 0.357), TBI subtype (P = 0.305), Glasgow Coma Scale (GCS) total score (P = 0.193), unconsciousness (P = 0.485), traumatic subarachnoid hemorrhage (tSAH) (P = 0.102), unresponsive pupil (P = 1.000), midline shift (P = 0.409), cisterns compressed or absent (P = 0.485), surgery side (P = 0.795), and interval from TBI (P = 0.840) between the two groups. The CO group was associated with better cognitive function in WAIS-RC OIQ (P = 0.030) and WAIS-RC FIQ (P = 0.021) and better daily function in IADL (P = 0.028) and ADL total (P = 0.030). The DC group also had a lower GOSE (P = 0.004) score compared to the CO group. No difference was observed in WAIS-VIQ (P = 0.062), WMS-RC MQ (P = 0.162), and PSMS (P = 0.319). Conclusion In the matched cohort, patients who underwent CO had better long-term outcomes in cognitive and daily function compared with DC. Future randomized control trials are needed for intensive studies on physical and neuropsychological prognosis in TBI patients.
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Affiliation(s)
- Zhengqian Guo
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wantao Ding
- Wenzhou Seventh People's Hospital, Wenzhou, China
| | - Dan Cao
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jian Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Jing X, Wang X, Zhuang H, Fang X, Xu H. Multiple Machine Learning Approaches Based on Postoperative Prediction of Pulmonary Complications in Patients With Emergency Cerebral Hemorrhage Surgery. Front Surg 2022; 8:797872. [PMID: 35127804 PMCID: PMC8812295 DOI: 10.3389/fsurg.2021.797872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022] Open
Abstract
Objective This study aimed to create a prediction model of postoperative pulmonary complications for the patients with emergency cerebral hemorrhage surgery. Methods Patients with hemorrhage surgery who underwent cerebral hemorrhage surgery were included and divided into two groups: patients with or without pulmonary complications. Patient characteristics, previous history, laboratory tests, and interventions were collected. Univariate and multivariate logistic regressions were used to predict postoperative pulmonary infection. Multiple machine learning approaches have been used to compare their importance in predicting factors, namely K-nearest neighbor (KNN), stochastic gradient descent (SGD), support vector classification (SVC), random forest (RF), and logistics regression (LR), as they are the most successful and widely used models for clinical data. Results Three hundred and fifty four patients with emergency cerebral hemorrhage surgery between January 1, 2017 and December 31, 2020 were included in the study. 53.7% (190/354) of the patients developed postoperative pulmonary complications (PPC). Stepwise logistic regression analysis revealed four independent predictive factors associated with pulmonary complications, including current smoker, lymphocyte count, clotting time, and ASA score. In addition, the RF model had an ideal predictive performance. Conclusions According to our result, current smoker, lymphocyte count, clotting time, and ASA score were independent risks of pulmonary complications. Machine learning approaches can also provide more evidence in the prediction of pulmonary complications.
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Affiliation(s)
- Xiaolei Jing
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Xueqi Wang
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Hongxia Zhuang
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Xiang Fang
- Division of Life Sciences and Medicine, Department of Neurology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Hao Xu
- Division of Life Sciences and Medicine, Department of Neurosurgery, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
- *Correspondence: Hao Xu
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Qian X, Zhang C, Zhou Z, Cao X, Zhang C, Chen T, Wang Y. Controlled decompression attenuates brain damage in a rat model of epidural extreme intracranial hypertension: Partially via inhibiting necroptosis and inflammatory response. Neurochem Int 2021; 153:105257. [PMID: 34952103 DOI: 10.1016/j.neuint.2021.105257] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022]
Abstract
Intracranial hypertension (IH) remains a common symptom of neurological diseases, and requires stepwise treatments to release intracranial pressure (ICP). In the present study, we built a rat model of epidural extreme intracranial hypertension (EEIH) and verified the effectiveness of a surgery method called controlled decompression on attenuating brain injury induced by EEIH. For the model part, we determined the level of EEIH of rats via recording ICP and cerebral perfusion pressure (CPP) and the variation tendency of survival rates, mean blood artery pressure and mean velocity (Vm) of left middle cerebral artery (LMCA) as ICP ascending. SD rats were assigned into 4 groups: Sham group, Controlled decompression group (Con group), Rapid decompression group (Rap group) and Rapid decompression + Necrostatin-1 (Nec-1) group (Rap+Nec-1 group). The results suggested that controlled decompression lowered cerebral water content, improved neurological function, and attenuated EEIH-induced inflammation response and ROS generation to a greater extent than rapid decompression. Meanwhile, controlled decompression functioned to preserve more Nissl bodies, indicating alleviated neuron injury after EEIH. Additionally, the permeability of blood brain barrier (BBB) was also safeguarded in the Con group. Western blotting (WB) and Real-time Polymerase Chain Reaction (rt-PCR) assays consistently determined lower protein and mRNA levels of necroptosis-related molecules receptor interacting protein kinase 1 (RIPK1), interacting protein kinase 3 (RIPK3) and mixed lineage kinase domain-like protein (MLKL) (WB only) in the Con and Rap+Nec-1 group. Double immunofluorescent staining found weaker fluorescence intensity of RIPK3 in the compressed cortex of the Con and Rap+Nec-1 group.
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Affiliation(s)
- Xiao Qian
- Department of Neurosurgery, The 904th Hospital of PLA, Medical School of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Chonghui Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Medical School of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Zhaopeng Zhou
- Department of Neurosurgery, The 904th Hospital of PLA, Medical School of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Xinyi Cao
- Department of Neurosurgery, The 904th Hospital of PLA, Medical School of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Chunlei Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Medical School of Anhui Medical University, Wuxi, Jiangsu, 214044, China
| | - Tao Chen
- Department of Neurosurgery, The 904th Hospital of PLA, Medical School of Anhui Medical University, Wuxi, Jiangsu, 214044, China.
| | - Yuhai Wang
- Department of Neurosurgery, The 904th Hospital of PLA, Medical School of Anhui Medical University, Wuxi, Jiangsu, 214044, China.
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Direct Consequences of Cranioplasty to the Brain: Intracranial Pressure Study. J Craniofac Surg 2021; 32:2779-2783. [PMID: 34727479 DOI: 10.1097/scs.0000000000007945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Intracranial pressure (ICP) is a crucial factor that we need to take into account in all major pathophysiological changes of the brain after decompressive craniectomy (DC) and cranioplasty (CP). The purpose of our study was to check ICP values before and after cranioplasty and its relation to various parameters (imaging, demographics, time of cranioplasty, and type of graft) as well as its possible relation to postsurgical complications. The authors performed a prospective study in which they selected as participants adults who had undergone unilateral frontotemporoparietal DC and were planned to have cranioplasty. Intracranial pressure was measured with optical fiber sensor in the epidural space and did not affect cranioplasty in any way.Twenty-five patients met the criteria. The mean vcICP (value change of ICP) was 1.2 mm Hg, the mean ΔICP (absolute value change of the ICP) was 2.24 mm Hg and in the majority of cases there was an increase in ICP. The authors found 3 statistically significant correlations: between gender and ΔICP, Δtime (time between DC and CP) and vcICP, and pre-ICP and ±ICP (quantitative change of the ICP).Μale patients tend to develop larger changes of ICP values during CP. As the time between the 2 procedures (DC and CP) gets longer, the vcICP is decreased. However, after certain time it shows a tendency to remain around zero. Lower pre-ICP values (close to or below zero) are more possible to increase after bone flap placement. It seems that the brain tends to restore its pre-DC conditions after CP by taking near-to-normal ICP values.
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Post-Cranioplasty Complications: Lessons From a Prospective Study Assessing Risk Factors. J Craniofac Surg 2021; 32:530-534. [PMID: 33704976 DOI: 10.1097/scs.0000000000007344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Complication rate related with cranioplasty is described as very high in most of relevant studies. The aim of our study was to try to identify possible factors, that could predict complications following cranioplasty. The authors hypothesized that some physical characteristics on the preoperative brain computed tomography (CT) scan can be predictive for complications.The authors carried out a prospective observational study. All patients were adults after decompressive craniectomy, planned for cranioplasty and had a brain CT scan the day before cranioplasty. Our data pool included demographics, reason of craniectomy, various radiological parameters, the time of cranioplasty after craniectomy, the type of cranioplasty bone flap, and the complications.Twenty-five patients were included in the study. The authors identified statistically significant correlation between time of cranioplasty after craniectomy and the complications, as well as between the type of cranioplasty implant and the complications. There was statistically significant correlation between complications and the distance of the free brain surface from the level of the largest skull defect dimension - free brain surface deformity (FBSD). Moreover, the correlation between FBSD and the time of cranioplasty was statistically significant.It seems that for adult patients with unilateral DC the shorter time interval between craniectomy and cranioplasty lowers the risk for complications. The risk seems to be decreased further, by using autologous bone flap. Low values of the FBSD increase the risk for complications. This risk factor can be avoided, by shortening the time between craniectomy and cranioplasty.
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Koo J, Lee J, Lee SH, Moon JH, Yang SY, Cho KT. Does the Size of Unilateral Decompressive Craniectomy Impact Clinical Outcomes in Patients with Intracranial Mass Effect after Severe Traumatic Brain Injury? Korean J Neurotrauma 2021; 17:3-14. [PMID: 33981638 PMCID: PMC8093026 DOI: 10.13004/kjnt.2021.17.e10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/20/2021] [Accepted: 03/18/2021] [Indexed: 11/15/2022] Open
Abstract
Objective Decompressive craniectomy (DC) is one of the treatment modalities in severe traumatic brain injury (TBI), however, there was a lack of evidence for optimal craniectomy size. The authors aimed to investigate optimal DC size and analyze clinical outcome according to craniectomy size. Methods We retrospectively reviewed the medical data of 87 patients with a space occupying lesion following TBI who underwent unilateral DC. Craniectomy size was measured by anterior-posterior (AP) diameter and surface estimate (SE). Mortality, clinical outcome, and complications were collected and analyzed according to craniectomy size. Results Nineteen patients (21.8%) died and 35 patients (40.2%) had a favorable outcome at last follow-up (a mean duration, 30.3±39.4 months; range, 0.2-132.6 months). Receiver operating curve analyses identified AP diameter more than 12.5 cm (area under the curve [AUC]=0.740; p=0.002) and SE more than 98.0 cm2 (AUC=0.752; p=0.001) as cut-off values for survival, and AP diameter more than 13.4 cm (AUC=0.650; p=0.018) and SE more than 107.3 cm2 (AUC=0.685; p=0.003) for favorable outcome. Large craniectomy resulted in a significantly lower mortality rate and a higher rate of favorable outcome than small craniectomy (p=0.005 and p=0.014, respectively). However, procedure related bleeding occurred more frequently in the large craniectomy group (p=0.044). Conclusion Unilateral DC size is associated with clinical outcome of patients with a space occupying lesion following severe TBI. Large craniectomy is needed for survival and favorable outcome.
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Affiliation(s)
- Jinhwan Koo
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jeongjun Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Su Hwan Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jung Hyeon Moon
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Seung-Yeob Yang
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Keun-Tae Cho
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
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Mraček J, Mork J, Dostal J, Tupy R, Mrackova J, Priban V. Complications Following Decompressive Craniectomy. J Neurol Surg A Cent Eur Neurosurg 2021; 82:437-445. [PMID: 33618416 DOI: 10.1055/s-0040-1721001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) has become the definitive surgical procedure to manage a medically intractable rise in intracranial pressure. DC is a life-saving procedure resulting in lower mortality but also higher rates of severe disability. Although technically straightforward, DC is accompanied by many complications. It has been reported that complications are associated with worse outcome. We reviewed a series of patients who underwent DC at our department to establish the incidence and types of complications. METHODS We retrospectively evaluated the incidence of complications after DC performed in 135 patients during the time period from January 2013 to December 2018. Postoperative complications were evaluated using clinical status and CT during 6 months of follow-up. In addition, the impact of potential risk factors on the incidence of complications and the impact of complications on outcome were assessed. RESULTS DC was performed in 135 patients, 93 of these for trauma, 22 for subarachnoid hemorrhage, 13 for malignant middle cerebral artery infarction, and 7 for intracerebral hemorrhage. Primary DC was performed in 120 patients and secondary DC in 15 patients. At least 1 complication occurred in each of 100 patients (74%), of which 22 patients (22%) were treated surgically. The following complications were found: edema or hematoma of the temporal muscle (34 times), extracerebral hematoma (33 times), extra-axial fluid collection (31 times), hemorrhagic progression of contusions (19 times), hydrocephalus (12 times), intraoperative malignant brain edema (10 times), temporal muscle atrophy (7 times), significant intraoperative blood loss (6 times), epileptic seizures (5 times), and skin necrosis (4 times). Trauma (p = 0.0006), coagulopathy (p = 0.0099), and primary DC (p = 0.0252) were identified as risk factors for complications. There was no significant impact of complications on outcome. CONCLUSIONS The incidence of complications following DC is high. However, we did not confirm a significant impact of complications on outcome. We emphasize that some phenomena are so frequent that they can be considered a consequence of primary injury or natural sequelae of the DC rather than its direct complication.
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Affiliation(s)
- Jan Mraček
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Jan Mork
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Jiri Dostal
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Radek Tupy
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Jolana Mrackova
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
| | - Vladimir Priban
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Neurosurgery, University Hospital Pilsen, Pilsen, Czech Republic
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Adatia K, Newcombe VFJ, Menon DK. Contusion Progression Following Traumatic Brain Injury: A Review of Clinical and Radiological Predictors, and Influence on Outcome. Neurocrit Care 2021; 34:312-324. [PMID: 32462411 PMCID: PMC7253145 DOI: 10.1007/s12028-020-00994-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Secondary injuries remain an important cause of the morbidity and mortality associated with traumatic brain injury (TBI). Progression of cerebral contusions occurs in up to 75% of patients with TBI, and this contributes to subsequent clinical deterioration and requirement for surgical intervention. Despite this, the role of early clinical and radiological factors in predicting contusion progression remains relatively poorly defined due to studies investigating progression of all types of hemorrhagic injuries as a combined cohort. In this review, we summarize data from recent studies on factors which predict contusion progression, and the effect of contusion progression on clinical outcomes.
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Affiliation(s)
- Krishma Adatia
- Division of Anaesthesia, University of Cambridge, Cambridge, UK.
| | | | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
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21
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Hanko M, Grendár M, Snopko P, Opšenák R, Šutovský J, Benčo M, Soršák J, Zeleňák K, Kolarovszki B. Random Forest-Based Prediction of Outcome and Mortality in Patients with Traumatic Brain Injury Undergoing Primary Decompressive Craniectomy. World Neurosurg 2021; 148:e450-e458. [PMID: 33444843 DOI: 10.1016/j.wneu.2021.01.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/01/2021] [Accepted: 01/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Various prognostic models are used to predict mortality and functional outcome in patients after traumatic brain injury with a trend to incorporate machine learning protocols. None of these models is focused exactly on the subgroup of patients indicated for decompressive craniectomy. Evidence regarding efficiency of this surgery is still incomplete, especially in patients undergoing primary decompressive craniectomy with evacuation of traumatic mass lesions. METHODS In a prospective study with a 6-month follow-up period, we assessed postoperative outcome and mortality of 40 patients who underwent primary decompressive craniectomy for traumatic brain injuries during 2018-2019. The results were analyzed in relation to a wide spectrum of preoperatively available demographic, clinical, radiographic, and laboratory data. Random forest algorithms were trained for prediction of both mortality and unfavorable outcome, with their accuracy quantified by area under the receiver operating curves (AUCs) for out-of-bag samples. RESULTS At the end of the follow-up period, we observed mortality of 57.5%. Favorable outcome (Glasgow Outcome Scale [GOS] score 4-5) was achieved by 30% of our patients. Random forest-based prediction models constructed for 6-month mortality and outcome reached a moderate predictive ability, with AUC = 0.811 and AUC = 0.873, respectively. Random forest models trained on handpicked variables showed slightly decreased AUC = 0.787 for 6-month mortality and AUC = 0.846 for 6-month outcome and increased out-of-bag error rates. CONCLUSIONS Random forest algorithms show promising results in prediction of postoperative outcome and mortality in patients undergoing primary decompressive craniectomy. The best performance was achieved by Classification Random forest for 6-month outcome.
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Affiliation(s)
- Martin Hanko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic.
| | - Marián Grendár
- Bioinformatic Center, Biomedical Center Martin (BioMed), Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Pavol Snopko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - René Opšenák
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Juraj Šutovský
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Martin Benčo
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Jakub Soršák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Branislav Kolarovszki
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
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Svedung Wettervik T, Lenell S, Enblad P, Lewén A. Decompressive Craniectomy in Traumatic Brain Injury-Craniectomy-Related and Cranioplasty-Related Complications in a Single Center. World Neurosurg 2021; 148:e508-e517. [PMID: 33444838 DOI: 10.1016/j.wneu.2021.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) relieves intracranial hypertension after severe traumatic brain injury (TBI), but it has been associated with poor clinical outcome in 2 recent randomized controlled trials. In this study, we investigated the incidence and explanatory variables for DC-related and cranioplasty (CP)-related complications after TBI. METHODS In this retrospective study, we identified 61 patients with TBI who were treated with DC in the neurointensive care unit, Uppsala University Hospital, Sweden, between 2008 and 2018. Demography, admission status, radiology, and clinical outcome were analyzed. RESULTS Eleven patients (18%) were reoperated because of postoperative hemorrhage after DC. Six (10%) developed postoperative infection during neurointensive care. Twenty-eight (46%) developed subdural hygromas and 10 (16%) received a permanent cerebrospinal fluid shunt. Sixteen patients (26%) died before CP. Median time to CP was 7 months (range, 2-19 months) and 32 (71%) were operated on with autologous bone and 13 (29%) with synthetic material primarily. In 9 patients with autologous bone (29%), the CP had to be replaced because of bone resorption/infection, whereas this did not occur after synthetic material (P = 0.04). However, all 4 postoperative hemorrhages after CP occurred when synthetic material was used (P = 0.005). CONCLUSIONS DC and CP surgery have a high risk for complications, leading to additional neurosurgery in about one third of cases. Synthetic CP materials may decrease the risk of reoperation, but special care with hemostasis is required because of increased risk of postoperative hemorrhage. Future trials need to address these topics to further improve the outcome for these patients.
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Affiliation(s)
| | - Samuel Lenell
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Khan I, Quddusi A, Waqas M, Rai HH, Bakhshi SK, Shamim MS, Jooma R. Hemorrhagic complications after decompressive craniectomy. Surg Neurol Int 2020; 11:379. [PMID: 33408913 PMCID: PMC7771395 DOI: 10.25259/sni_607_2019] [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: 12/30/2019] [Accepted: 06/26/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Decompressive craniectomy (DC) is the preferred surgical management option for lowering refractory intracranial pressure in cases of traumatic brain injury (TBI). A number of randomized controlled trials have demonstrated decreased mortality but increased morbidity following DC for TBI patients. Here, we reviewed the frequency of postoperative hemorrhagic complications following DC correlating with poor outcomes. Methods: We retrospectively reviewed the medical records of patients who presented with TBI and underwent DC during the years 2015–2017. The frequency and characteristics of hemorrhagic complications were correlated with the patients’ outcomes. Results: There were 74 patients with TBI included in the study who underwent DC. Of these, 31 patients developed expansion of existing hemorrhagic lesions, 13 had new contusions, three developed new extradural hemorrhages, two developed new subdural hematomas, and one patient developed an intraventricular hemorrhage. Those who developed expansion of existing hemorrhagic lesions following DC had longer ICU stays and poorer outcomes (Glasgow outcome scale). Conclusion: After 74 DC performed in TBI patients, 67% developed new hemorrhagic lesions or expansion of previously existing hemorrhages. This finding negatively impacted clinical outcomes, including mortality.
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Affiliation(s)
- Inamullah Khan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ayesha Quddusi
- Department of Neuroscience, Centre for Neuroscience, Queens University, Kingston, Ontario, Canada
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo, 40 George Karl Blvd, Williamsville, Buffalo, New York, United States
| | - Hamid Hussain Rai
- Department of Neurosurgery, University at Buffalo, 40 George Karl Blvd, Williamsville, Buffalo, New York, United States
| | | | | | - Rashid Jooma
- Department of Surgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
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24
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Miki K, Nonaka M, Kobayashi H, Horio Y, Abe H, Morishita T, Iwaasa M, Inoue T. Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience. Neurosurg Rev 2020; 44:1635-1643. [PMID: 32700161 DOI: 10.1007/s10143-020-01351-x] [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: 03/26/2020] [Revised: 06/19/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023]
Abstract
Recently, treatment of acute subdural hematoma (ASDH) by minimally invasive surgery with endoscopy has been successfully demonstrated. However, few case series are available on this procedure for ASDH, and the surgical indication has not been established. We retrospectively analyzed the data of patients (n = 26) aged 65 years or older who underwent endoscopic surgery (ES) for ASDH at our institution between January 2011 and March 2019. We then evaluated the surgical outcomes and procedure-related complications in patients who underwent ES. The mean hematoma reduction rate was over 90%. Percentage of favorable outcomes at discharge was 69.2% in ES-treated patients. The presence of a skull fracture, subarachnoid hemorrhage, midline shift/subdural hematoma thickness ratio > 1.0, and early surgery were associated with postoperative IPHs in patients who underwent ES or conventional surgery for ASDH. The present study revealed that ES for elderly patients with ASDH is likely to be an efficient and safe procedure when patients are selected appropriately. However, ES is not recommended in patients with significant IPHs on initial CT scan. Additionally, ES should be carefully considered in cases with the factors, where IPHs may progress following surgery.
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Affiliation(s)
- Koichi Miki
- Department of Neurosurgery, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Masani Nonaka
- Department of Neurosurgery, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Hiromasa Kobayashi
- Department of Neurosurgery, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Yoshinobu Horio
- Department of Neurosurgery, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Hiroshi Abe
- Department of Neurosurgery, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Takashi Morishita
- Department of Neurosurgery, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Mitsutoshi Iwaasa
- Department of Emergency and Critical Care, Faculty of Medicine, Fukuoka University Hospital and School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tooru Inoue
- Department of Neurosurgery, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
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Baldon IV, Amorim AC, Santana LM, Solla DJ, Kolias A, Hutchinson P, Paiva WS, Rosa-Júnior M. The extravasation of contrast as a predictor of cerebral hemorrhagic contusion expansion, poor neurological outcome and mortality after traumatic brain injury: A systematic review and meta-analysis. PLoS One 2020; 15:e0235561. [PMID: 32634141 PMCID: PMC7340282 DOI: 10.1371/journal.pone.0235561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/17/2020] [Indexed: 01/14/2023] Open
Abstract
Background The active extravasation of contrast on CT angiography (CTA) in primary intracerebral hemorrhages (ICH) is recognized as a predictive factor for ICH expansion, unfavorable outcomes and mortality. However, few studies have been conducted on the setting of traumatic brain injury (TBI). Purpose To perform a literature systematic review and meta-analysis of the association of contrast extravasation on cerebral hemorrhagic contusion expansion, neurological outcomes and mortality. Data sources The PubMed, Cochrane Library, Medline, Scielo, VHL and IBECS databases up to September 21, 2019, were searched for eligible studies. Study selection A total of 505 individual titles and abstracts were identified and screened. A total of 36 were selected for full text analysis, out of which 4 fulfilled all inclusion and exclusion criteria. Data analysis All 4 studies yielded point estimates suggestive of higher risk for hematoma expansion with contrast extravasation and the summary RR was 5.75 (95%CI 2.74–10.47, p<0.001). Contrast extravasation was also associated with worse neurological outcomes (RR 3.25, 95%CI 2.24–4.73, p<0.001) and higher mortality (RR 2.77, 95%CI 1.03–7.47, p = 0.04). Data synthesis This study is a Systematic Review and Meta-Analysis revealed the extravasation of contrast is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality. Limitations Only four articles were selected. Conclusions The extravasation of contrast in the setting of TBI is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.
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Affiliation(s)
- Isabella Vargas Baldon
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
| | - Andre Candeas Amorim
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
| | - Larissa Marques Santana
- Department of Radiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
| | - Davi J. Solla
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas of the University of São Paulo, São Paulo, Brazil
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Angelos Kolias
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s, Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Peter Hutchinson
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s, Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Wellingson S. Paiva
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas of the University of São Paulo, São Paulo, Brazil
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Marcos Rosa-Júnior
- Department of Neuroradiology, Hospital Universitário Cassiano Antônio de Moraes da Universidade Federal do Espírito Santo – HUCAM/UFES/EBSERH, Vitória, State of Espírito Santo, Brazil
- * E-mail:
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Mathieu F, Zeiler FA, Ercole A, Monteiro M, Kamnitsas K, Glocker B, Whitehouse DP, Das T, Smielewski P, Czosnyka M, Hutchinson PJ, Newcombe VF, Menon DK. Relationship between Measures of Cerebrovascular Reactivity and Intracranial Lesion Progression in Acute Traumatic Brain Injury Patients: A CENTER-TBI Study. J Neurotrauma 2020; 37:1556-1565. [PMID: 31928143 PMCID: PMC7307675 DOI: 10.1089/neu.2019.6814] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Failure of cerebral autoregulation has been linked to unfavorable outcome after traumatic brain injury (TBI). Preliminary evidence from a small, retrospective, single-center analysis suggests that autoregulatory dysfunction may be associated with traumatic lesion expansion, particularly for pericontusional edema. The goal of this study was to further explore these associations using prospective, multi-center data from the Collaborative European Neurotrauma Effectiveness Research in TBI (CENTER-TBI) and to further explore the relationship between autoregulatory failure, lesion progression, and patient outcome. A total of 88 subjects from the CENTER-TBI High Resolution ICU Sub-Study cohort were included. All patients had an admission computed tomography (CT) scan and early repeat scan available, as well as high-frequency neurophysiological recordings covering the between-scan interval. Using a novel, semiautomated approach at lesion segmentation, we calculated absolute changes in volume of contusion core, pericontusional edema, and extra-axial hemorrhage between the imaging studies. We then evaluated associations between cerebrovascular reactivity metrics and radiological lesion progression using mixed-model regression. Analyses were adjusted for baseline covariates and non-neurophysiological factors associated with lesion growth using multi-variate methods. Impairment in cerebrovascular reactivity was significantly associated with progression of pericontusional edema and, to a lesser degree, intraparenchymal hemorrhage. In contrast, there were no significant associations with extra-axial hemorrhage. The strongest relationships were observed between RAC-based metrics and edema formation. Pulse amplitude index showed weaker, but consistent, associations with contusion growth. Cerebrovascular reactivity metrics remained strongly associated with lesion progression after taking into account contributions from non-neurophysiological factors and mean cerebral perfusion pressure. Total hemorrhagic core and edema volumes on repeat CT were significantly larger in patients who were deceased at 6 months, and the amount of edema was greater in patients with an unfavourable outcome (Glasgow Outcome Scale-Extended 1-4). Our study suggests associations between autoregulatory failure, traumatic edema progression, and poor outcome. This is in keeping with findings from a single-center retrospective analysis, providing multi-center prospective data to support those results.
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Affiliation(s)
- François Mathieu
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Frederick A. Zeiler
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnibeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnibeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnibeg, Manitoba, Canada
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Miguel Monteiro
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | | | - Ben Glocker
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | | | - Tilak Das
- Department of Radiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter J. Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
| | | | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
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Cepeda S, Castaño-León AM, Munarriz PM, Paredes I, Panero I, Eiriz C, Gómez PA, Lagares A. Effect of decompressive craniectomy in the postoperative expansion of traumatic intracerebral hemorrhage: a propensity score-based analysis. J Neurosurg 2020; 132:1623-1635. [PMID: 31026834 DOI: 10.3171/2019.2.jns182025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 02/04/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic intracerebral hemorrhage (TICH) represents approximately 13%-48% of the lesions after a traumatic brain injury (TBI), and hemorrhagic progression (HP) occurs in 38%-63% of cases. In previous studies, decompressive craniectomy (DC) has been characterized as a risk factor in the HP of TICH; however, few studies have focused exclusively on this relationship. The object of the present study was to analyze the relationship between DC and the growth of TICH and to reveal any correlation with the size of the craniectomy, degree of cerebral parenchymal herniation (CPH), or volumetric expansion of the TICH. METHODS The authors retrospectively analyzed the records of 497 adult patients who had been consecutively admitted after suffering a severe or moderate closed TBI. An inclusion criterion was presentation with one or more TICHs on the initial or control CT. Demographic, clinical, radiological, and treatment variables were assessed for associations. RESULTS Two hundred three patients presenting with 401 individual TICHs met the selection criteria. TICH growth was observed in 281 cases (70.1%). Eighty-two cases (20.4%) underwent craniectomy without TICH evacuation. In the craniectomy group, HP was observed in 71 cases (86.6%); in the noncraniectomy group (319 cases), HP occurred in 210 cases (65.8%). The difference in the incidence of HP between the two groups was statistically significant (OR 3.41, p < 0.01). The mean area of the craniectomy was 104.94 ± 27.5 cm2, and the mean CPH distance through the craniectomy was 17.85 ± 11.1 mm. The mean increase in the TICH volume was greater in the groups with a craniectomy area > 115 cm2 and CPH > 25 mm (16.12 and 14.47 cm3, respectively, p = 0.01 and 0.02). After calculating the propensity score (PS), the authors followed three statistical methods-matching, stratification, and inverse probability treatment weighting (IPTW)-thereby obtaining an adequate balance of the covariates. A statistically significant relationship was found between HP and craniectomy (OR 2.77, p = 0.004). This correlation was confirmed with the three methodologies based on the PS with odds greater than 2. CONCLUSIONS DC is a risk factor for the growth of TICH, and there is also an association between the size of the DC and the magnitude of the volume increase in the TICH.
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Affiliation(s)
- Santiago Cepeda
- 1Department of Neurosurgery, University Hospital Río Hortega, Valladolid
- 3University Complutense, Madrid, Spain
| | - Ana María Castaño-León
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and
- 3University Complutense, Madrid, Spain
| | - Pablo M Munarriz
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and
- 3University Complutense, Madrid, Spain
| | - Igor Paredes
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and
- 3University Complutense, Madrid, Spain
| | - Irene Panero
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and
- 3University Complutense, Madrid, Spain
| | - Carla Eiriz
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and
- 3University Complutense, Madrid, Spain
| | - Pedro A Gómez
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and
- 3University Complutense, Madrid, Spain
| | - Alfonso Lagares
- 2Department of Neurosurgery, University Hospital 12 de Octubre, Instituto de Investigación i+12, Madrid; and
- 3University Complutense, Madrid, Spain
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Hanko M, Soršák J, Snopko P, Opšenák R, Zeleňák K, Kolarovszki B. Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: a 5-year experience. Eur J Trauma Emerg Surg 2020; 47:1635-1647. [PMID: 32307561 DOI: 10.1007/s00068-020-01367-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Decompressive craniectomy is an effective measure to reduce a pathologically elevated intracranial pressure. Patients' survival and life quality following this surgery have been a subject of several studies and significantly differ according to the primary diagnosis. Since this operation is often associated with a wide spectrum of possibly serious complications, we aimed to describe their incidence and possible associated risk factors. METHODS We evaluated 118 patients who underwent decompressive craniectomy at our clinic during years 2013-2017. The indications included traumatic brain injuries, ischaemic or haemorrhagic strokes and postoperative complications of planned neurosurgical procedures. Subsequently, we assessed the incidence of early postoperative complications (occurring during the first 3 postoperative weeks). The results were statistically analysed with relation to a wide selection of possible risk factors. RESULTS At least one early surgical postoperative complication occurred in 87 (73.73%) patients, the most frequent being a development of an extraaxial fluid collection in 41 (34.75%) patients. We were able to identify risk factors linked with extraaxial fluid collections, subcutaneous and extradural haematomas, postoperative seizures and meningitis. An overall need for reoperation was 13.56%. Neither the duration of the surgery nor the qualification of the operating surgeon had any effect on the complications' occurrence. CONCLUSIONS Decompressive craniectomy is associated with numerous early postoperative complications with a various degree of severity. Most cases of complications can, however, be managed in a conservative way. The risk factors linked with postoperative complications should be taken into account during the indication process in each individual patient.
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Affiliation(s)
- Martin Hanko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Jakub Soršák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Pavol Snopko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - René Opšenák
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Branislav Kolarovszki
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic.
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Comparative Radiographic Factors Predicting Functional Outcome After Decompressive Craniectomy in Severe Traumatic Brain Injury. World Neurosurg 2020; 138:e876-e882. [PMID: 32251815 DOI: 10.1016/j.wneu.2020.03.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Decompressive craniectomy (DC) is a last-tier therapy in the treatment of raised intracranial pressure after traumatic brain injury (TBI). We report the association of comparative radiographic factors in predicting functional outcomes after DC in patients with severe TBI. METHODS A retrospective analysis of a prospectively maintained database of cases between 2015 and 2018 at an academic tertiary care hospital was carried out. Univariate and multivariable regression analyses were performed for an array of comparative radiographic variables (pre- and post-DC) in relationship to functional outcome according to Glasgow Outcome Scale Extended (GOSE) at 180 days. GOSE was further dichotomized into favorable (GOSE:5-8) and unfavorable (GOSE:0-4) functional outcomes. All associations were reported as odds ratio (OR) with 95% confidence interval (CI). RESULTS Statistical analysis included a cohort of 43 patients with a median age of 30.5 years (range: 18-62 years). The median GOSE at 180 days was 7. Multivariable regression analysis after adjusting for confounding variables (age, sex, comorbidities, site of surgery and size of decompression) showed that comparative radiographic findings of midline shift (MLS) > 10 mm (OR 3.2 (95% CI 1.25-8.04); P = 0.01); external cerebral herniation (ECH) > 2.5 cm (OR 2.5 [95% CI 1.18-5.2]; P = 0.02); and effacement of basal cisterns (OR 3.9 [95%CI 1.1-13.9]; P = 0.03), were significant independent predictors of poor functional outcome at 180 days after DC for severe TBI. However, the presence of infarction (OR 2.7 [95%CI 0.43-17.2]; P = 0.28) and absence of gray-white matter differentiation (OR 0.18 [95%CI 0.03-1.2]; P = 0.07) did not reach statistical significance. CONCLUSIONS The comparative radiographic findings that include MLS > 10mm, ECH > 2.5cm, and effacement of basal cisterns are predictive of poor functional outcome in severe TBI.
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Mathieu F, Zeiler FA, Whitehouse DP, Das T, Ercole A, Smielewski P, Hutchinson PJ, Czosnyka M, Newcombe VFJ, Menon DK. Relationship Between Measures of Cerebrovascular Reactivity and Intracranial Lesion Progression in Acute TBI Patients: an Exploratory Analysis. Neurocrit Care 2020; 32:373-382. [PMID: 31797278 PMCID: PMC7082305 DOI: 10.1007/s12028-019-00885-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Failure of cerebral autoregulation and progression of intracranial lesion have both been shown to contribute to poor outcome in patients with acute traumatic brain injury (TBI), but the interplay between the two phenomena has not been investigated. Preliminary evidence leads us to hypothesize that brain tissue adjacent to primary injury foci may be more vulnerable to large fluctuations in blood flow in the absence of intact autoregulatory mechanisms. The goal of this study was therefore to assess the influence of cerebrovascular reactivity measures on radiological lesion expansion in a cohort of patients with acute TBI. METHODS We conducted a retrospective cohort analysis on 50 TBI patients who had undergone high-frequency multimodal intracranial monitoring and for which at least two brain computed tomography (CT) scans had been performed in the acute phase of injury. We first performed univariate analyses on the full cohort to identify non-neurophysiological factors (i.e., initial lesion volume, timing of scan, coagulopathy) associated with traumatic lesion growth in this population. In a subset analysis of 23 patients who had intracranial recording data covering the period between the initial and repeat CT scan, we then correlated changes in serial volumetric lesion measurements with cerebrovascular reactivity metrics derived from the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC (correlation coefficient between the pulse amplitude of intracranial pressure and cerebral perfusion pressure). Using multivariate methods, these results were subsequently adjusted for the non-neurophysiological confounders identified in the univariate analyses. RESULTS We observed significant positive linear associations between the degree of cerebrovascular reactivity impairment and progression of pericontusional edema. The strongest correlations were observed between edema progression and the following indices of cerebrovascular reactivity between sequential scans: % time PRx > 0.25 (r = 0.69, p = 0.002) and % time PAx > 0.25 (r = 0.64, p = 0.006). These associations remained significant after adjusting for initial lesion volume and mean cerebral perfusion pressure. In contrast, progression of the hemorrhagic core and extra-axial hemorrhage volume did not appear to be strongly influenced by autoregulatory status. CONCLUSIONS Our preliminary findings suggest a possible link between autoregulatory failure and traumatic edema progression, which warrants re-evaluation in larger-scale prospective studies.
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Affiliation(s)
- François Mathieu
- Division of Neurosurgery, University of Toronto, Toronto, Canada.
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK.
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Frederick A Zeiler
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Daniel P Whitehouse
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Tilak Das
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Hills Road, Box 218, Cambridge, CB2 0QQ, UK
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Peter J Hutchinson
- Brain Physics LaboratoryDivision of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 167, Cambridge, CB2 0QQ, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Virginia F J Newcombe
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
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Stevens RD, Koehler RC. Pathophysiological Insights into Spreading Depolarization in Severe Traumatic Brain Injury. Neurocrit Care 2020; 30:569-571. [PMID: 30877553 DOI: 10.1007/s12028-019-00705-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Robert D Stevens
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Phipps 455, Baltimore, MD, 21287, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Neurostereologic Lesion Volumes and Spreading Depolarizations in Severe Traumatic Brain Injury Patients: A Pilot Study. Neurocrit Care 2020; 30:557-568. [PMID: 30972614 DOI: 10.1007/s12028-019-00692-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Spreading depolarizations (SDs) occur in 50-60% of patients after surgical treatment of severe traumatic brain injury (TBI) and are independently associated with unfavorable outcomes. Here we performed a pilot study to examine the relationship between SDs and various types of intracranial lesions, progression of parenchymal damage, and outcomes. METHODS In a multicenter study, fifty patients (76% male; median age 40) were monitored for SD by continuous electrocorticography (ECoG; median duration 79 h) following surgical treatment of severe TBI. Volumes of hemorrhage and parenchymal damage were estimated using unbiased stereologic assessment of preoperative, postoperative, and post-ECoG serial computed tomography (CT) studies. Neurologic outcomes were assessed at 6 months by the Glasgow Outcome Scale-Extended. RESULTS Preoperative volumes of subdural and subarachnoid hemorrhage, but not parenchymal damage, were significantly associated with the occurrence of SDs (P's < 0.05). Parenchymal damage increased significantly (median 34 ml [Interquartile range (IQR) - 2, 74]) over 7 (5, 8) days from preoperative to post-ECoG CT studies. Patients with and without SDs did not differ in extent of parenchymal damage increase [47 ml (3, 101) vs. 30 ml (- 2, 50), P = 0.27], but those exhibiting the isoelectric subtype of SDs had greater initial parenchymal damage and greater increases than other patients (P's < 0.05). Patients with temporal clusters of SDs (≥ 3 in 2 h; n = 10 patients), which included those with isoelectric SDs, had worse outcomes than those without clusters (P = 0.03), and parenchymal damage expansion also correlated with worse outcomes (P = 0.01). In multivariate regression with imputation, both clusters and lesion expansion were significant outcome predictors. CONCLUSIONS These results suggest that subarachnoid and subdural blood are important primary injury factors in provoking SDs and that clustered SDs and parenchymal lesion expansion contribute independently to worse patient outcomes. These results warrant future prospective studies using detailed quantification of TBI lesion types to better understand the relationship between anatomic and physiologic measures of secondary injury.
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Decompressive Craniectomy for Patients with Traumatic Brain Injury: A Pooled Analysis of Randomized Controlled Trials. World Neurosurg 2020; 133:e135-e148. [DOI: 10.1016/j.wneu.2019.08.184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/21/2022]
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Guan H, Zhang C, Chen T, Zhu J, Yang S, Shu L, Shen W, Wang Y. Controlled Decompression Attenuates Brain Injury in a Novel Rabbit Model of Acute Intracranial Hypertension. Med Sci Monit 2019; 25:9776-9785. [PMID: 31859264 PMCID: PMC6933874 DOI: 10.12659/msm.919796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background In the past, standard rapid decompressive craniectomy was used to alleviate the secondary damage caused by high intracranial pressure. Recent clinical studies showed that controlled decompression may have a better curative effect than rapid decompression. However, the effect on controlled decompression in animals is unclear. Material/Methods Totally 80 healthy male New Zealand rabbits were randomly divided into a sham group (n=20), a rapid decompression group (n=30), and a controlled decompression group (n=30). An intracranial hypertension model was induced by injecting saline into an epidural balloon catheter and reducing ICP slowly and gradually by use of a pressure pump. The model was evaluated and analyzed by general observations, imaging examination, ICP values, behavioral score, brain water content, Nissl staining, and caspase-3 protein detection. Results The mortality rate was 36.7% (11/30) in the rapid group, 20% (6/30) in the controlled group, and 5% (1/20) in the sham group. The incidence of epidural hematoma in the controlled group was lower than in the rapid group (p<0.01). The ICP was significantly lower in the controlled group than in the rapid group (p<0.001), and the behavioral score in the rapid group was higher than in the controlled group (p<0.05). There was a marked difference in brain water content between the controlled group and the rapid group (p<0.01). Nissl staining demonstrated that the ratio of Nissl body in the controlled group was significantly higher than in the rapid group (p<0.01). WB detection showed the expression of Caspase-3 in the controlled group was lower than in the rapid group (p<0.05). Conclusions The results show the advantages of use of controlled decompression with intracranial hypertension. The animal model we developed provides a platform for further research on controlled decompression.
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Affiliation(s)
- Haoxiang Guan
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Can Zhang
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Tao Chen
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Jie Zhu
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Shuo Yang
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Longfei Shu
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Wei Shen
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Yuhai Wang
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
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Vankipuram S, Sasane SV, Chandra A, Ojha BK, Singh SK, Srivastava C, Jaiswal S, Bajaj A, Jaiswal M. A Comparative Analysis Between Four-Quadrant Osteoplastic Decompressive Craniotomy versus Conventional Decompressive Craniectomy for Traumatic Brain Injury. World Neurosurg 2019; 135:e393-e404. [PMID: 31821915 DOI: 10.1016/j.wneu.2019.12.004] [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: 09/22/2019] [Revised: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Primary decompressive craniectomy (DC) is indicated to evacuate the hematoma and reduce intracranial pressure in traumatic brain injury (TBI). However, there are a myriad of complications because of absence of the bone flap. A novel technique, four-quadrant osteoplastic decompressive craniotomy (FoQOsD) retains the bone flap while achieving adequate cerebral decompression. METHODS A single-center randomized controlled trial of 115 patients with TBI needing decompressive surgery was conducted. Of these patients, 59 underwent DC and 56 underwent FoQOsD. The primary outcome determined was functional status at 6 months using the Glasgow Outcome Scale-Extended. RESULTS No significant differences were identified in baseline characteristics between both groups. Mean Glasgow Outcome Scale-Extended score was comparable at 6 months (4.28 in DC vs. 4.38 in FoQOsD; P = 0.856). Further, 22 of 58 patients in the DC group had died (38%) compared with 25 of 55 patients in the FoQOsD group (44.6%) (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.6-2.36; P = 0.6) (1 patient lost to follow-up in each group). A favorable outcome was seen in 56.8% of patients in the DC group versus 54.4% of patients in the FoQOsD group (P = 0.74). Presence of intraventricular hemorrhage and subarachnoid hemorrhage (OR, 7.17; 95% CI, 1.364-37.7; P = 0.020), opposite side contusions (OR, 3.838; 95% CI, 1.614-9.131; P = 0.002) and anisocoria (OR, 3.235; 95% CI, 1.490-7.026; P = 0.003) preoperatively were individual factors that played a significant role in final outcome. CONCLUSIONS FoQOsD is as efficacious as conventional DC with the added benefit of avoiding a second surgery. The procedure is associated with better cosmesis and fewer complications.
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Affiliation(s)
- Siddharth Vankipuram
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India.
| | - Sumeet V Sasane
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Anil Chandra
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Bal K Ojha
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Sunil K Singh
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Chhitij Srivastava
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Somil Jaiswal
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Ankur Bajaj
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Manish Jaiswal
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
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Huang PK, Sun YZ, Xie XL, Kang DZ, Zheng SF, Yao PS. Twist drill craniostomy for traumatic acute subdural hematoma in the elderly: case series and literature review. Chin Neurosurg J 2019; 5:10. [PMID: 32922910 PMCID: PMC7398353 DOI: 10.1186/s41016-019-0157-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 04/01/2019] [Indexed: 11/29/2022] Open
Abstract
Background A large craniotomy is usually the first choice for removal of traumatic acute subdural hematoma (TASDH). To date, few studies have reported that TASDH could be successfully treated by twist drill craniostomy (TDC) alone or combined with instillation of urokinase. We aimed to define the TDC for the elderly with TASDH and performed literature review. Case presentation A total of 7 TASDH patients, who were presented and treated by TDC in this retrospective study between January 2009 and May 2017, consisted of 5 men and 2 women, ranging in age from 65 to 89 (average, 78.9) years. The patients’ baseline characteristics, including age, sex, medical history, received ventriculoperitoneal shunt for hydrocephalus or not, reason for avoiding or refusing large craniotomy, preoperative Glasgow Coma Scale (GCS), suffered from cerebral herniation or not, the location of TASDH, imaging characteristics of TASDH in CT scan, injury/surgery time interval, midline shift, preoperative neurologic deficit, operation time, and infusions of urokinase or not, were collected. The postoperative GCS, postoperative neurologic deficit, rebleeding or not, intracranial infection, and modified Rankin Scale (mRS) at 6 months after surgery were analyzed to access the safety and efficacy of evacuation with TDC. The results showed that the mean time interval from injury to TDC was 68.6 min (30–120 min). The mean distance of midline shift was 14.6 mm (10–20 mm). The preoperative GCS in all patients ranged from 4 to 13(median, 9). The mean duration of the operation was 14.4 min (6–19 min). Postoperative CT scan showed that hematoma evacuation rate was more than 70% in all cases. There were no cases of acute rebleeding and intracranial infection after TDC. No cases presented with chronic SDH at the ipsilateral side within 6 months after being treated by TDC alone or combined with instillation of urokinase. Favorable outcomes were shown in all cases (mRS scores 0–2) at 6 months after surgery. Conclusions TASDH in the elderly could be safely and effectively treated by TDC alone or combined with instillation of urokinase, which was a possible alternative for the elderly.
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Affiliation(s)
- Pei-Kun Huang
- Fujian Medical University, Fuzhou, 350004 China.,Department of Neurosurgery, Hui'an County Hospital, Hui'an, 362100 China
| | - Yong-Zhong Sun
- Department of Neurosurgery, Hui'an County Hospital, Hui'an, 362100 China
| | - Xue-Ling Xie
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou, 350004 China
| | - De-Zhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou, 350004 China
| | - Shu-Fa Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou, 350004 China
| | - Pei-Sen Yao
- The First Clinical Medical College of Fujian Medical University, NO. 20 Chazhong Road, Taijiang District, Fuzhou, 350004 China
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Pérez‐Alfayate R, Sallabanda‐Diaz K. Primary bilateral fronto-temporoparietal decompressive craniectomy-An alternative treatment for severe traumatic brain injury: Case report and technical note. Clin Case Rep 2019; 7:1031-1039. [PMID: 31110740 PMCID: PMC6509892 DOI: 10.1002/ccr3.2143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/05/2019] [Accepted: 03/23/2019] [Indexed: 11/12/2022] Open
Abstract
Bilateral fronto-temporoparietal decompressive craniectomy provides bigger area of the decompression that decreases the brain tissue herniation; therefore, it leads to a decrease in the neuronal stretching effect that is probably related to functional outcomes.
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Desse N, Beucler N, Dagain A. How I do it: supra-tentorial unilateral decompressive craniectomy. Acta Neurochir (Wien) 2019; 161:895-898. [PMID: 30953153 DOI: 10.1007/s00701-019-03880-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/20/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Decompressive craniectomy is a surgical way to treat intracranial hypertension, by removing a large flap of skull bone. METHOD We report the case of a 48 years old right-handed man presenting an acute ischaemic stroke of all the right sylvian artery area, with rapid clinic deterioration then coma. Severe intracranial hypertension was confirmed by transcranial Doppler. In emergency, we decided to perform a right-side decompressive craniectomy. CONCLUSION Six months later, he is in rehabilitation with "only" a left hemiplegia and a very good relational life. His modified Rankin score is 3. Decompressive craniectomy saved this patient's life, that is why we think this surgical technique must be explained and mastered.
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Affiliation(s)
- Nicolas Desse
- Service de Neurochirurgie, Hôpital d'Instruction des Armées Sainte Anne, HIA Sainte Anne - BP600, 83800, Toulon Cedex 9, France.
| | - Nathan Beucler
- Service de Neurochirurgie, Hôpital d'Instruction des Armées Sainte Anne, HIA Sainte Anne - BP600, 83800, Toulon Cedex 9, France
| | - Arnaud Dagain
- Service de Neurochirurgie, Hôpital d'Instruction des Armées Sainte Anne, HIA Sainte Anne - BP600, 83800, Toulon Cedex 9, France
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Nasi D, di Somma L, Gladi M, Moriconi E, Scerrati M, Iacoangeli M, Dobran M. New or Blossoming Hemorrhagic Contusions After Decompressive Craniectomy in Traumatic Brain Injury: Analysis of Risk Factors. Front Neurol 2019; 9:1186. [PMID: 30697186 PMCID: PMC6340989 DOI: 10.3389/fneur.2018.01186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/24/2018] [Indexed: 01/02/2023] Open
Abstract
Background: The development or expansion of a cerebral hemorrhagic contusion after decompressive craniectomy (DC) for traumatic brain injury (TBI) occurs commonly and it can result in an unfavorable outcome. However, risk factors predicting contusion expansion after DC are still uncertain. The aim of this study was to identify the factors associated with the growth or expansion of hemorrhagic contusion after DC in TBI. Then we evaluated the impact of contusion progression on outcome. Methods: We collected the data of patients treated with DC for TBI in our Center. Then we analyzed the risk factors associated with the growth or expansion of a hemorrhagic contusion after DC. Results: 182 patients (149 males and 41 females) were included in this study. Hemorrhagic contusions were detected on the initial CT scan or in the last CT scan before surgery in 103 out of 182 patients. New or blossoming hemorrhagic contusions were registered after DC in 47 patients out of 182 (25.82%). At multivariate analysis, only the presence of an acute subdural hematoma (p = 0.0076) and a total volume of contusions >20 cc before DC (p = < 0.0001) were significantly associated with blossoming contusions. The total volume of contusions before DC resulted to have higher accuracy and ability to predict postoperative blossoming of contusion with strong statistical significance rather than the presence of acute subdural hematoma (these risk factors presented respectively an area under the curve [AUC] of 0.896 vs. 0.595; P < 0.001). Patients with blossoming contusions presented an unfavorable outcome compared to patients without contusion progression (p < 0.0185). Conclusions: The presence of an acute subdural hematoma was associated with an increasing rate of new or expanded hemorrhagic contusions after DC. The total volume of hemorrhagic contusions > 20 cc before surgery was an independent and extremely accurate predictive radiological sign of contusion blossoming in decompressed patients for severe TBI. After DC, the patients who develop new or expanding contusions presented an increased risk for unfavorable outcome.
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Affiliation(s)
- Davide Nasi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Lucia di Somma
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Gladi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Elisa Moriconi
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Massimo Scerrati
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Umberto I General Hospital, Università Politecnica delle Marche, Ancona, Italy
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Di G, Zhang Y, Liu H, Jiang X, Liu Y, Yang K, Chen J, Liu H. Postoperative complications influencing the long-term outcome of head-injured patients after decompressive craniectomy. Brain Behav 2019; 9:e01179. [PMID: 30511376 PMCID: PMC6346640 DOI: 10.1002/brb3.1179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 11/03/2018] [Accepted: 11/06/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Postoperative complications are common in patients who underwent decompressive craniectomy (DC) after traumatic brain injury (TBI). However, little is known about the degree of association between the postoperative complications and the long-term outcome of adult TBI patients after DC. The aim of this study was to evaluate the risk of postoperative complications that influenced the long-term outcome of DC in TBI patients. METHOD A total of 121 patients were studied up to 6 months after DC in TBI. The collected data included demographic, clinical and radiological information, postoperative complications, and Glasgow Outcome Scale-Extended (GOSE) scores at follow-up 6 months after DC. Based on their GOSE scores, they were divided into two functional groups: favorable (GOSE = 5-8) or unfavorable outcome (GOSE = 2-4) group. The characteristics of the two groups were compared using statistical analysis. Finally, a regression model was established and a receiver operating characteristic (ROC) curve was applied to analyze its performance power. RESULTS Of 121 admitted patients, 31 (25.62%) sustained an unfavorable outcome. A logistic regression analysis showed that the presence of Glasgow Coma Scale (GCS) scores on admission (odds ratio [OR] 0.285, p = 0.001), posttraumatic hydrocephalus (PTH) (OR 8.688, p = 0.003), craniectomy site (OR 8.068, p = 0.033), and postoperative progressive hemorrhagic injury (PHI) (OR 6.196, p = 0.026) were independent risk factors that correlated with an unfavorable outcome. Analysis using ROC curves demonstrated that these factors had different accuracies in predicting an unfavorable outcome (AUC = 0.852 for GCS scores on admission; AUC = 0.826 for PTH, AUC = 0.617 for craniectomy site; AUC = 0.616 for postoperative PHI). The performance power of the GCS scores on admission and PTH influenced the patient's outcomes to a similar degree (p = 0.623), and either predicted the outcome better than the craniectomy site or the postoperative PHI (p < 0.05, respectively). CONCLUSION These findings suggest that the occurrence of PTH and postoperative PHI were independently associated with an unfavorable long-term outcome after DC in patients with TBI. Early prevention and treatment of PTH and postoperative PHI may be beneficial to improve the long-term outcome, especially in patients with lower admission GCS scores or bilateral DC.
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Affiliation(s)
- Guangfu Di
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Yuhai Zhang
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
| | - Hua Liu
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
| | - Xiaochun Jiang
- Department of Neurosurgery, First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Yong Liu
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
| | - Kun Yang
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
| | - Jiu Chen
- Institute of Neuropsychiatry, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China.,Institute of Brain Functional Imaging, Nanjing Medical University, Nanjing, China
| | - Hongyi Liu
- Department of Neurosurgery, The Affiliated Brain Hospital with Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, China
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Gopalakrishnan MS, Shanbhag NC, Shukla DP, Konar SK, Bhat DI, Devi BI. Complications of Decompressive Craniectomy. Front Neurol 2018; 9:977. [PMID: 30524359 PMCID: PMC6256258 DOI: 10.3389/fneur.2018.00977] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/30/2018] [Indexed: 11/13/2022] Open
Abstract
Decompressive craniectomy (DC) has become the definitive surgical procedure to manage medically intractable rise in intracranial pressure due to stroke and traumatic brain injury. With incoming evidence from recent multi-centric randomized controlled trials to support its use, we could expect a significant rise in the number of patients who undergo this procedure. Although one would argue that the procedure reduces mortality only at the expense of increasing the proportion of the severely disabled, what is not contested is that patients face the risk of a large number of complications after the operation and that can further compromise the quality of life. Decompressive craniectomy (DC), which is designed to overcome the space constraints of the Monro Kellie doctrine, perturbs the cerebral blood, and CSF flow dynamics. Resultant complications occur days to months after the surgical procedure in a time pattern that can be anticipated with advantage in managing them. New or expanding hematomas that occur within the first few days can be life-threatening and we recommend CT scans at 24 and 48 h postoperatively to detect them. Surgeons should also be mindful of the myriad manifestations of peculiar complications like the syndrome of the trephined and neurological deterioration due to paradoxical herniation which may occur many months after the decompression. A sufficiently large frontotemporoparietal craniectomy, 15 cm in diameter, increases the effectiveness of the procedure and reduces chances of external cerebral herniation. An early cranioplasty, as soon as the brain is lax, appears to be a reasonable choice to mitigate many of the late complications. Complications, their causes, consequences, and measures to manage them are described in this chapter.
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Affiliation(s)
- M S Gopalakrishnan
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Nagesh C Shanbhag
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhaval P Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Subhas K Konar
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - B Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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Letter to the Editor Regarding “Cisternostomy for Refractory Posttraumatic Intracranial Hypertension”. World Neurosurg 2018; 112:311-312. [DOI: 10.1016/j.wneu.2018.01.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 12/27/2022]
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Paletta N, Maali L, Zahran A, Sethuraman S, Figueroa R, Nichols FT, Bruno A. A Simplified Quantitative Method to Measure Brain Shifts in Patients with Middle Cerebral Artery Stroke. J Neuroimaging 2017; 28:61-63. [DOI: 10.1111/jon.12482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 10/11/2017] [Indexed: 11/28/2022] Open
Affiliation(s)
- Nina Paletta
- School of Medicine, Medical College of Georgia; Augusta University; Augusta GA
| | - Laith Maali
- Department of Neurology; University of Kansas; Lawrence KS
| | - Abdurrehman Zahran
- Department of Radiology, Medical College of Georgia; Augusta University; Augusta GA
| | | | - Ramon Figueroa
- Department of Radiology, Medical College of Georgia; Augusta University; Augusta GA
| | - Fenwick T. Nichols
- Department of Radiology, Medical College of Georgia; Augusta University; Augusta GA
- Department of Neurology; Medical College of Georgia, Augusta University; Augusta GA
| | - Askiel Bruno
- Department of Neurology; Medical College of Georgia, Augusta University; Augusta GA
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Yue JK, Rick JW, Deng H, Feldman MJ, Winkler EA. Efficacy of decompressive craniectomy in the management of intracranial pressure in severe traumatic brain injury. J Neurosurg Sci 2017; 63:425-440. [PMID: 29115100 DOI: 10.23736/s0390-5616.17.04133-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Traumatic brain injury (TBI) is a common cause of permanent disability for which clinical management remains suboptimal. Elevated intracranial pressure (ICP) is a common sequela following TBI leading to death and permanent disability if not properly managed. While clinicians often employ stepwise acute care algorithms to reduce ICP, a number of patients will fail medical management and may be considered for surgical decompression. Decompressive craniectomy (DC) involves removing a component of the bony skull to allow cerebral tissue expansion in order to reduce ICP. However, the impact of DC, which is performed in the setting of neurological instability, ongoing secondary injury, and patient resuscitation, has been challenging to study and outcomes are not well understood. This review summarizes historical and recent studies to elucidate indications for DC and the nuances, risks and complications in its application. The pathophysiology driving ICP elevation, and the corresponding medical interventions for their temporization and treatment, are thoroughly described. The current state of DC - including appropriate injury classification, surgical techniques, concurrent medical therapies, mortality and functional outcomes - is presented. We also report on the recent updates from large randomized controlled trials in severe TBI (Decompressive Craniectomy [DECRA] and Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP [RESCUEicp]), and recommendations for early DC to treat refractory ICP elevations in malignant middle cerebral artery syndrome. Limitations for DC, such as the equipoise between immediate reduction in ICP and clinically meaningful functional outcomes, are discussed in support of future investigations.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Jonathan W Rick
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael J Feldman
- Department of Neurological Surgery, Vanderbilt University, Nashville, TN, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA -
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Kramer AH, Deis N, Ruddell S, Couillard P, Zygun DA, Doig CJ, Gallagher C. Decompressive Craniectomy in Patients with Traumatic Brain Injury: Are the Usual Indications Congruent with Those Evaluated in Clinical Trials? Neurocrit Care 2017; 25:10-9. [PMID: 26732269 DOI: 10.1007/s12028-015-0232-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND In patients with traumatic brain injury (TBI), multicenter randomized controlled trials have assessed decompressive craniectomy (DC) exclusively as treatment for refractory elevation of intracranial pressure (ICP). DC reliably lowers ICP but does not necessarily improve outcomes. However, some patients undergo DC as treatment for impending or established transtentorial herniation, irrespective of ICP. METHODS We performed a population-based cohort study assessing consecutive patients with moderate-severe TBI. Indications for DC were compared with enrollment criteria for the DECRA and RESCUE-ICP trials. RESULTS Of 644 consecutive patients, 51 (8 %) were treated with DC. All patients undergoing DC had compressed basal cisterns, 82 % had at least temporary preoperative loss of ≥1 pupillary light reflex (PLR), and 80 % had >5 mm of midline shift. Most DC procedures (67 %) were "primary," having been performed concomitantly with evacuation of a space-occupying lesion. ICP measurements influenced the decision to perform DC in 18 % of patients. Only 10 and 16 % of patients, respectively, would have been eligible for the DECRA and RESCUE-ICP trials. DC improved basal cistern compression in 76 %, and midline shift in 94 % of patients. Among patients with ≥1 absent PLR at admission, DC was associated with lower mortality (46 vs. 68 %, p = 0.03), especially when the admission Marshall CT score was 3-4 (p = 0.0005). No patients treated with DC progressed to brain death. Variables predictive of poor outcome following DC included loss of PLR(s), poor motor score, midline shift ≥11 mm, and development of perioperative cerebral infarcts. CONCLUSIONS DC is most often performed for clinical and radiographic evidence of herniation, rather than for refractory ICP elevation. Results of previously completed randomized trials do not directly apply to a large proportion of patients undergoing DC in practice.
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Affiliation(s)
- Andreas H Kramer
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada. .,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada. .,Hotchkiss Brain Institute, Calgary, AB, Canada.
| | - Nathan Deis
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Stacy Ruddell
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada
| | - Philippe Couillard
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, Calgary, AB, Canada
| | - David A Zygun
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Christopher J Doig
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Clare Gallagher
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, Calgary, AB, Canada
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Gutman MJ, How E, Withers T. The floating anchored craniotomy. Surg Neurol Int 2017; 8:130. [PMID: 28713633 PMCID: PMC5502294 DOI: 10.4103/sni.sni_460_16] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 02/01/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The "floating anchored" craniotomy is a technique utilized at our tertiary neurosurgery institution in which a traditional decompressive craniectomy has been substituted for a floating craniotomy. The hypothesized advantages of this technique include adequate decompression, reduction in the intracranial pressure, obviating the need for a secondary cranioplasty, maintained bone protection, preventing the syndrome of the trephined, and a potential reduction in axonal stretching. METHODS The bone plate is re-attached via multiple loosely affixed vicryl sutures, enabling decompression, but then ensuring the bone returns to its anatomical position once cerebral edema has subsided. RESULTS From the analysis of 57 consecutive patients analyzed at our institution, we have found that the floating anchored craniotomy is comparable to decompressive craniectomy for intracranial pressure reduction and has some significant theoretical advantages. CONCLUSIONS Despite the potential advantages of techniques that avoid the need for a second cranioplasty, they have not been widely adopted and have been omitted from trials examining the utility of decompressive surgery. This retrospective analysis of prospectively collected data suggests that the floating anchored craniotomy may be applicable instead of decompressive craniectomy.
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Affiliation(s)
- Matthew J. Gutman
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Australia
| | - Elena How
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Australia
| | - Teresa Withers
- Department of Neurosurgery, Gold Coast University Hospital, Southport, Australia
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Parichay PJ, Khanapure K, Joshi KC, Aniruddha TJ, Sandhya M, Hegde AS. Clinical and radiological assessment of cerebral hemodynamics after cranioplasty for decompressive craniectomy - A Clinical study. J Clin Neurosci 2017; 42:97-101. [PMID: 28457859 DOI: 10.1016/j.jocn.2017.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 04/03/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To find the correlation between radiologically proven improvement in cerebral hemodynamics with clinical improvement in patients undergoing cranioplasty. MATERIAL AND METHODS The study is a prospective observational study of 10 cases, in M S Ramaiah Institute of Neurosciences, involving patients treated by a decompressive craniectomy for intractable intra cranial hypertension either due to trauma or stroke and afterwards underwent cranioplasty. RESULTS Of the 10 patients, 70% patients showing significant improvement in motor functions on Barthel index scale, 60% patients showed improvement in speech, mean duration from date of decompressive craniectomy to cranioplasty being 122.4days. Cerebral perfusion was remarkably better after cranioplasty, as demonstrated decrease in the Pulsatility index on the ipsilateral side of decompression on Trans cranial Doppler (<0.73 mean). This data also favored improved cerebral blood flow and permeability on the CT perfusion with increase in cerebral blood flow (CBF), Cerebral Blood Volume (CBV) and decrease in Time to Peak (TTP) and a positive outcome when correlated with Barthel index with P-values of 0.093, 0.017 and 0.001 respectively. CONCLUSION Cranioplasty influences the cerebral hemodynamics after cranioplasty and has a positive correlation on the functional outcome and cerebral blood flow in the MCA territory.
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Affiliation(s)
- Perikal J Parichay
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India.
| | - Kiran Khanapure
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India
| | - Krishna C Joshi
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India
| | - T J Aniruddha
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India
| | - M Sandhya
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neuro Science (NIMHANS), Bangalore, India
| | - A S Hegde
- Department of Neurosurgery, M S Ramaiah Institute of Neurosciences, M S Ramaiah Medical College, New BEL Road, Bangalore 54, India
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Intracranial pressure monitoring after primary decompressive craniectomy in traumatic brain injury: a clinical study. Acta Neurochir (Wien) 2017; 159:615-622. [PMID: 28236181 DOI: 10.1007/s00701-017-3118-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/14/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring represents an important tool in the management of traumatic brain injury (TBI). Although current information exists regarding ICP monitoring in secondary decompressive craniectomy (DC), little is known after primary DC following emergency hematoma evacuation. METHODS Retrospective analysis of prospectively collected data. Inclusion criteria were age ≥18 years and admission to the intensive care unit (ICU) for TBI and ICP monitoring after primary DC. Exclusion criteria were ICU length of stay (LOS) <1 day and pregnancy. Major objectives were: (1) to analyze changes in ICP/cerebral perfusion pressure (CPP) after primary DC, (2) to evaluate the relationship between ICP/CPP and neurological outcome and (3) to characterize and evaluate ICP-driven therapies after DC. RESULTS A total of 34 patients were enrolled. Over 308 days of ICP/CPP monitoring, 130 days with at least one episode of intracranial hypertension (26 patients, 76.5%) and 57 days with at least one episode of CPP <60 mmHg (22 patients, 64.7%) were recorded. A statistically significant relationship was discovered between the Glasgow Outcome Scale (GOS) scores and mean post-decompression ICP (p < 0.04) and between GOS and CPP minimum (CPPmin) (p < 0.04). After DC, persisting intracranial hypertension was treated with: barbiturate coma (n = 7, 20.6%), external ventricular drain (EVD) (n = 4, 11.8%), DC diameter widening (n = 1, 2.9%) and removal of newly formed hematomas (n = 3, 8.8%). CONCLUSION Intracranial hypertension and/or low CPP occurs frequently after primary DC; their occurence is associated with an unfavorable neurological outcome. ICP monitoring appears useful in guiding therapy after primary DC.
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Adams H, Kolias AG, Hutchinson PJ. The Role of Surgical Intervention in Traumatic Brain Injury. Neurosurg Clin N Am 2016; 27:519-28. [DOI: 10.1016/j.nec.2016.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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50
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Stoner KE, Abode-Iyamah KO, Grosland NM, Howard MA. Volume of Brain Herniation in Patients with Ischemic Stroke After Decompressive Craniectomy. World Neurosurg 2016; 96:101-106. [PMID: 27591100 DOI: 10.1016/j.wneu.2016.08.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/22/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Decompressive craniectomy procedures are performed in patients with malignant intracranial hypertension. A bone flap is removed to relieve pressure. Later, a second operation is performed to reconstruct the skull after brain swelling has resolved. This surgical treatment would be improved if it were possible to perform a single operation that decompressed the brain acutely and eliminated the need for a second operation. To design a device and procedure that achieve this objective, it is essential to understand how the brain swells after a craniectomy procedure. METHODS We identified 20 patients with ischemic stroke who underwent a decompressive hemicraniectomy operation. Skull defect morphology and postoperative brain swelling were measured using computed tomography scan data. Additional intracranial volume created by placing a hypothetical cranial plate implant offset from the skull surface by 5 mm was measured for each patient. RESULTS The average craniectomy area and brain herniation volume was 9999 ± 1283 mm2 and 30.48 ± 23.56 mL, respectively. In all patients, the additional volume created by this hypothetical implant exceeded the volume of brain herniation observed. CONCLUSIONS These findings show that a cranial plate with a 5-mm offset accommodates the brain swelling that occurs in this patient population.
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Affiliation(s)
- Kirsten E Stoner
- Department of Biomedical Engineering, University of Iowa, Seamans Center for the Engineering Arts and Sciences, Iowa City, Iowa, USA
| | | | - Nicole M Grosland
- Department of Biomedical Engineering, University of Iowa, Seamans Center for the Engineering Arts and Sciences, Iowa City, Iowa, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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