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Hatchimonji JS, Meredyth NA, Gummadi S, Kaufman EJ, Yelon JA, Cannon JW, Martin ND, Seamon MJ. The role of emergency department thoracotomy in patients with cranial gunshot wounds. J Trauma Acute Care Surg 2024; 97:220-224. [PMID: 38374530 DOI: 10.1097/ta.0000000000004282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
BACKGROUND Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. METHODS We used Pennsylvania Trauma Outcomes Study data, 2002 to 2021, and included EDTs for GSWs. We defined EDT by International Classification of Diseases codes for thoracotomy or procedures requiring one, with a location flagged as emergency department. We defined head injuries as any head Abbreviated Injury Scale (AIS) score of ≥1 and severe head injuries as head AIS score of ≥4. Head injuries were "isolated" if all other body regions have an AIS score of <2. Descriptive statistics were performed. Discharge functional status was measured in five domains. RESULTS Over 20 years in Pennsylvania, 3,546 EDTs were performed; 2,771 (78.1%) were for penetrating injuries. Most penetrating EDTs (2,003 [72.3%]) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head injured (n = 94 of 1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound-0% (0 of 81) with a severe head injury ( p = 0.035 vs. no severe head injury) and 4.5% (5 of 110) with a nonsevere head injury. Of the five head-injured survivors, two were fully dependent for transfer mobility, and three were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. CONCLUSION Although there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Justin S Hatchimonji
- From the Division of Traumatology, Emergency Surgery, and Surgical Critical Care (J.S.H., S.G., E.J.K., J.A.Y., J.W.C., N.D.M., M.J.S.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma and Critical Care (N.A.M.), Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and Department of Surgery (J.A.Y.), Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, Maryland
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Breeze J, Whitford A, Gensheimer WG, Berg C. Physiological and radiological parameters predicting outcome from penetrating traumatic brain injury treated in the deployed military setting. BMJ Mil Health 2024; 170:228-231. [PMID: 36028282 DOI: 10.1136/military-2022-002118] [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: 03/16/2022] [Accepted: 08/07/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Penetrating traumatic brain injury (TBI) is the most common cause of death in current military conflicts, and results in significant morbidity in survivors. Identifying those physiological and radiological parameters associated with worse clinical outcomes following penetrating TBI in the austere setting may assist military clinicians to provide optimal care. METHOD All emergency neurosurgical procedures performed at a Role 3 Medical Treatment Facility in Afghanistan for penetrating TBI between 01 January 2016 and 18 December 2020 were analysed. The odds of certain clinical outcomes (death and functional dependence post-discharge) occurring following surgery were matched to existing agreed preoperative variables described in current US and UK military guidelines. Additional physiological and radiological variables including those comprising the Rotterdam criteria of TBI used in civilian settings were additionally analysed to determine their potential utility in a military austere setting. RESULTS 55 casualties with penetrating TBI underwent surgery, all either by decompressive craniectomy (n=42) or craniotomy±elevation of skull fragments (n=13). The odds of dying in hospital attributable to TBI were greater with casualties with increased glucose on arrival (OR=70.014, CI=3.0399 to 1612.528, OR=70.014, p=0.008) or a mean arterial pressure <90 mm Hg (OR=4.721, CI=0.969 to 22.979, p=0.049). Preoperative hyperglycaemia was also associated with increased odds of being functionally dependent on others on discharge (OR=11.165, CI=1.905 to 65.427, p=0.007). Bihemispheric injury had greater odds of being functionally dependent on others at discharge (OR=5.275, CI=1.094 to 25.433, p=0.038). CONCLUSIONS We would recommend that consideration of these three additional preoperative clinical parameters (hyperglycaemia, hypotension and bihemispheric injury on CT) when managing penetrating TBI be considered in future updates of guidelines for deployed neurosurgical care.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Department of Bioengineering, Imperial College London, London, UK
| | - A Whitford
- Gaza Barracks, Joint Hospital Group, Catterick, UK
| | - W G Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center Joint Base Andrews, Prince George's County, Maryland, USA
| | - C Berg
- Department of Neurosurgery, Wright-Patterson Air Force Base, Dayton, Ohio, USA
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Mansour A, Powla PP, Fakhri F, Alvarado-Dyer R, Das P, Horowitz P, Goldenberg FD, Lazaridis C. Comparative Effectiveness of Early Neurosurgical Intervention in Civilian Penetrating Brain Injury Management. Neurosurgery 2024; 94:470-477. [PMID: 37847039 DOI: 10.1227/neu.0000000000002725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/25/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To compare the outcomes of early vs no-neurosurgical intervention in civilians with penetrating brain injury (PBI). METHODS We collected data from the National Trauma Data Bank for PBI between 2017 and 2019. A total of 10 607 cases were identified; 1276 cases met the following criteria: age 16-60 years, an intensive care unit (ICU) length of stay (LOS) of >2 days, a Glasgow Coma Scale of 3-12, and at least one reactive pupil on presentation. Patients with withdrawal of life-sustaining treatments within 72 hours were excluded, leaving 1231 patients for analysis. Neurosurgical intervention was defined as an open-approach cranial procedure involving release, drainage, or extirpation of brain matter performed within 24 hours. Outcomes of interest were mortality, withdrawal of life-sustaining treatments, ICU LOS, and dispositional outcome. RESULTS The target population was 1231 patients (84.4% male; median [IQR] age, 29 [18] years); 267 (21.7%) died, and 364 (29.6%) had a neurosurgical intervention within the first 24 hours. 1:1 matching yielded 704 patients (352 in each arm). In the matched cohort (mortality 22.6%), 64 patients who received surgery (18.2%) died compared with 95 (27%) in the nonsurgical group. Survival was more likely in the surgical group (odds ratio [OR] 1.66, CI 1.16-2.38, P < .01; number needed to treat 11). Dispositional outcome was not different. Overlap propensity score-weighted analysis (1231 patients) resulted in higher odds of survival in the surgical group (OR 1.8, CI 1.16-2.80, P < .01). The E-value for the OR calculated from the matched data set was 2.83. Early neurosurgical intervention was associated with longer ICU LOS (median 12 days [7.0, 19.0 IQR] vs 8 days [4.0, 15.0 IQR], P < .05). CONCLUSION Management including early neurosurgical intervention is associated with decreased mortality and increased ICU LOS in matched cohorts of PBI.
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Affiliation(s)
- Ali Mansour
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Plamena P Powla
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Farima Fakhri
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Ronald Alvarado-Dyer
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Paramita Das
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Peleg Horowitz
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Fernando D Goldenberg
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
| | - Christos Lazaridis
- Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA
- Department of Neurosurgery, University of Chicago Medical Center, Chicago , Illinois , USA
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Beucler N. Letter to the Editor Regarding "Decompressive Hemicraniectomies as a Damage Control Approach for Multilobar Firearm Projectile Injuries: A Single-Center Experience". World Neurosurg 2023; 179:239-241. [PMID: 38059592 DOI: 10.1016/j.wneu.2023.05.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France; Ecole du Val-de-Grâce, French Military French Health Service Academy, Paris, France.
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Rainone GJ, Zelmanovich R, Laurent D, Lucke-Wold B. How War Has Shaped Neurosurgery. World Neurosurg 2023; 178:136-144. [PMID: 37506839 DOI: 10.1016/j.wneu.2023.07.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023]
Abstract
Many strides have been made in neurosurgery during times of war, helping to improve the outcomes of patients in dire circumstances. World War I introduced the concepts of early operation for trauma, forward-operating hospitals, and galeal sutures as well as techniques for careful debridement. It laid the groundwork for neurosurgery to become a specialty within medicine as well. World War II brought about the use of expedited medical evacuation, mobile neurosurgical units, improved resuscitation strategies, cranioplasty, and early laminectomy with decompression. The Korean and Vietnam Wars built on concepts from World Wars I and II, helping to establish the importance of watertight dural closure, external drainage systems after cranial trauma, multidisciplinary care, and infection prevention strategies. In the post-Vietnam period, we have seen significant technological advances allowing neurosurgeons to move farther ahead than most throughout history could have imagined. The significance of secondary brain injury, vascular injury, and the underlying pathophysiology of traumatic insults has been elucidated over the years since the Vietnam War, allowing for great advances in the care of our patients. Each major war throughout history has contributed greatly to the specialty of neurosurgery, each with its own innovations culminating in guidelines, strategies, and standards of practice that allow us to deliver the highest standard of care to our patients.
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Affiliation(s)
- Gersham J Rainone
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA.
| | - Rebecca Zelmanovich
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dimitri Laurent
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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Neurologically Intact Survival after Bihemispheric Penetrating Head Trauma: A Case Report. J Emerg Med 2023; 64:214-216. [PMID: 36813646 DOI: 10.1016/j.jemermed.2022.12.028] [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: 10/06/2022] [Revised: 11/10/2022] [Accepted: 12/13/2022] [Indexed: 02/23/2023]
Abstract
BACKGROUND Patients with penetrating head trauma that crosses the midline of the brain have a high mortality rate; most die in the prehospital setting or during initial resuscitative efforts. However, surviving patients are often neurologically intact and several factors other than bullet path, including post-resuscitation Glasgow Coma Scale, age, and pupillary abnormalities, must be considered in aggregate when prognosticating patients. CASE REPORT We present a case of an 18-year-old man who presented unresponsive after a single gunshot wound to the head that traversed the bilateral hemispheres. The patient was managed with standard care and without surgical intervention. He was discharged from the hospital neurologically intact 2 weeks after his injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with such apparently devastating injuries are at risk of premature termination of aggressive resuscitative efforts based on clinician bias that these efforts are futile and that patients cannot recover to a neurologically meaningful outcome. Our case reminds clinicians that patients with severe injury patterns with bihemispheric involvement can recover with good outcomes, and that bullet path is only one variable among multiple that must be considered to predict clinical outcome.
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Roberts B, James D, Haft J, Balakrishnan N, Prince J, Sathya C. Wounding patterns in pediatric firearm fatalities. Injury 2023; 54:154-159. [PMID: 36503841 DOI: 10.1016/j.injury.2022.11.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/06/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pediatric firearm injury became the leading cause of death among U.S. children in 2020. Studies evaluating wounding patterns in military and mass casualty shootings have provided insights into treatment and potential salvageability in adults, however, similar studies in the pediatric population do not exist. Hence, our study aimed to analyze wounding patterns of pediatric firearm fatalities and associated demographics and characteristics, such as place of death, to better understand pediatric firearm injuries, potential salvageability, and opportunities to reduce firearm deaths among vulnerable pediatric populations. METHODS A retrospective review of the National Violent Death Reporting System from 2005-2017 was performed on patients 18 and younger. Mortalities were stratified by patient age: <12 years and 13-18 years and by intent- homicide, suicide, and unintentional. Comparative and exploratory analyses of demographics, location of death and anatomic location of wounds were performed. RESULTS Of 8,527 pediatric firearm mortalities identified, 4,728 were homicides, 3,180 were suicides and 619 were unintentional injuries. Suicide victims were most likely to be dead on scene and >90% of suicide victims suffered head/neck injuries. For victims of homicide, younger children were more likely to die on scene (61% vs 44% p < 0.001). The pattern of injury in homicides differed for younger children compared to adolescents, with younger children with more head/neck injuries and older children more thoracic, thoracoabdominal, abdominal, and junctional injuries. In both age groups, children with extremity, abdominal and thoracoabdominal injuries were more likely to die later in the emergency department or inpatient setting. CONCLUSIONS Wounding patterns across pediatric firearm mortalities in the U.S. vary by age and intent. The majority of pediatric firearm deaths were due to head/neck injuries. Children with homicide and unintentional deaths had more wounding pattern variation, including more injuries to the thorax and abdomen, and a much lower rate of dead-on scene than suicide victims. Our study of wounding patterns among U.S. children killed by firearms highlights the complexity of these injuries and offers opportunities for tailored public health strategies across varying vulnerable pediatric populations.
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Affiliation(s)
- Bailey Roberts
- Cohen Children's Medical Center at Northwell Health, Zucker-Hofstra School of Medicine, United States
| | - Douglas James
- Garnet Health Medical Center, Touro College of Osteopathic Medicine, Middletown, NY
| | - Julia Haft
- Cohen Children's Medical Center at Northwell Health, Zucker-Hofstra School of Medicine, United States
| | - Nalini Balakrishnan
- Cohen Children's Medical Center at Northwell Health, Zucker-Hofstra School of Medicine, United States
| | - Jose Prince
- Cohen Children's Medical Center at Northwell Health, Zucker-Hofstra School of Medicine, United States
| | - Chethan Sathya
- Cohen Children's Medical Center at Northwell Health, Zucker-Hofstra School of Medicine, United States.
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Yousefi O, Azami P, Borazjani R, Niakan A, Yadollahi M, Khalili H. Civilian penetrating traumatic brain injury: A 5-year single-center experience. Surg Neurol Int 2023; 14:28. [PMID: 36895251 PMCID: PMC9990774 DOI: 10.25259/sni_1160_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Background The aim of this study was to report the demographics and clinical features of patients with penetrating traumatic brain injury (PTBI) during the past 5 years in Rajaee Hospital, a tertiary referral trauma center in Shiraz, southern Iran. Methods We conducted a 5-year retrospective evaluation of all patients diagnosed with PTBI who were referred to Rajaee Hospital. We retrieved the following items from the hospital's database and PACS system: patients' demographics, on-admission Glasgow Coma Scale (GCS), presence of trauma to other organs, duration of the hospital and ICU stay, the neurosurgical interventions, any necessity of tracheostomy, duration of ventilator dependency, the entrance point of the trauma in the skull, type of assault, length of trajectory in the brain parenchyma, the number of remaining objects in the brain, the occurrence of any hemorrhagic phenomenon, the cross of the bullet from the midline or coronal suture, and the presence of the pneumocephalus. Results A total of 59 patients with a mean age of 28.75 ± 9.40 had PTBI over the 5 years. The mortality rate was 8.5%. Stab wounds, shotguns, gunshots, and airguns were the cause of injury in 33 (56%), 14 (23.7%), 10 (17%), and 2 (3.4%) patients, respectively. The median initial GCS of patients was 15 (3-15). Intracranial hemorrhage was observed in 33 cases, subdural hematoma in 18 cases, intraventricular hemorrhage in eight cases, and subarachnoid hemorrhage in four cases. The mean duration of hospitalization was 10.05 ± 10.75 (ranging from 1 to 62 days). Furthermore, 43 patients experienced ICU admission with mean days of 6.5 ± 5.62 (1-23). The temporal and frontal regions were the most common entrance points, in 23 and 19 patients, respectively. Conclusion The incidence of PTBI is relatively low in our center, possibly due to the prohibition of possession or using warm weapons in Iran. Further, multicenter studies with larger sample sizes are needed to determine prognostic factors associated with worse clinical outcomes after PTBI.
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Affiliation(s)
- Omid Yousefi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pouria Azami
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Roham Borazjani
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Niakan
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahnaz Yadollahi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hosseinali Khalili
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Beucler N, Sellier A, Fawaz R, Dagain A. Letter to the Editor Regarding Outcomes Following Penetrating Brain Injuries in Military Settings: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 167:241-242. [PMID: 36793168 DOI: 10.1016/j.wneu.2022.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/05/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France; Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France.
| | - Aurore Sellier
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France
| | - Rayan Fawaz
- Neurosurgery Department, Percy Military Teaching Hospital, Clamart, France; Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
| | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France; Val-de-Grâce Military Academy, Paris, France
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A comparison of clinical characteristics, radiographic findings, and outcomes of bihemispheric versus unihemispheric gunshot wounds to the head. Am J Emerg Med 2022; 60:78-82. [DOI: 10.1016/j.ajem.2022.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/14/2022] [Accepted: 07/16/2022] [Indexed: 11/18/2022] Open
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Cakani B, Vyshka G, Gega P, Qirinxhi D. Through-and-through gunshot wound to the head in a rare case of survival. Clin Case Rep 2022; 10:e05566. [PMID: 35280106 PMCID: PMC8905135 DOI: 10.1002/ccr3.5566] [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: 11/10/2021] [Revised: 01/03/2022] [Accepted: 02/23/2022] [Indexed: 02/05/2023] Open
Abstract
We describe the case of a 42-year old Caucasian male who presented for follow-up treatment of refractory epilepsy. He suffered a cranial trauma 13 years before when a bullet from a pistol, (presumably accidentally) entered the right frontal side of the cranial vault and exited contralateral, causing severe neurological damage.
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Affiliation(s)
- Bujar Cakani
- Service of Internal MedicineDistrict Hospital of ElbasanElbasanAlbania
| | - Gentian Vyshka
- Faculty of MedicineBiomedical and Experimental DepartmentUniversity of Medicine in TiranaTiranaAlbania
| | - Petrit Gega
- Service of RadiologyDistrict Hospital of ElbasanElbasanAlbania
| | - Denis Qirinxhi
- Service of RadiologyUniversity Hospital Center of TiranaTiranaAlbania
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Wal A, Khandai M, Vig H, Srivastava P, Agarwal A, Wadhwani S, Wal P. Evidence-Based Treatment, assisted by Mobile Technology to Deliver, and Evidence-Based Drugs in South Asian Countries. ARCHIVES OF PHARMACY PRACTICE 2022. [DOI: 10.51847/d5zeajvk6x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Sellier A, Beucler N, Joubert C, Desse N, Dagain A. Letter to the Editor. Ballistic trajectory in civilian penetrating brain injury. J Neurosurg 2021; 135:664. [PMID: 33545671 DOI: 10.3171/2020.11.jns204043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Civilian Firearm-Inflicted Brain Injury: Coagulopathy, Vascular Injuries, and Triage. Curr Neurol Neurosci Rep 2021; 21:47. [PMID: 34244864 DOI: 10.1007/s11910-021-01131-0] [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: 06/16/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Civilian firearm-inflicted penetrating brain injury (PBI) carries high morbidity and mortality. Concurrently, the evidence base guiding management decisions remains limited. Faced with large volume of PBI patients, we have made observations in relation to coagulopathy and cerebrovascular injuries. We here review this literature in addition to the question about early prognostication as it may inform neurosurgical decision-making. RECENT FINDINGS The triad of coagulopathy, low motor score, and radiographic compression of basal cisterns comprises a phenotype of injury with exceedingly high mortality. PBI leads to high rates of cerebral arterial and venous injuries, and projectile trajectory is emerging as an independent predictor of outcome. The combination of coagulopathy with cerebrovascular injury creates a specific endophenotype. The nature and role of coagulopathy remain to be deciphered, and consideration to the use of tranexamic acid should be given. Prospective controlled trials are needed to create clinical evidence free of patient selection bias.
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Clinical Significance of Isolated Third Cranial Nerve Palsy in Traumatic Brain Injury: A Detailed Description of Four Different Mechanisms of Injury through the Analysis of Our Case Series and Review of the Literature. Emerg Med Int 2021; 2021:5550371. [PMID: 33976940 PMCID: PMC8087465 DOI: 10.1155/2021/5550371] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/18/2021] [Indexed: 11/24/2022] Open
Abstract
Third cranial nerve palsy (3cnP) following traumatic brain injury (TBI) is a worrying neurological sign and is often associated with an expanding mass lesion, such as extradural or acute subdural haematomas. Isolated 3cnP can be found in the absence of posttraumatic space-occupying mass lesion, yet it is often considered as a devastating prognostic factor in the context of diffuse axonal injury (DAI). Through the analysis of five exemplificative cases and a thorough review of the literature, we identified four possible mechanisms leading to 3cnP: (1) a partial rootlet avulsion at the site of exit from the midbrain, representing a direct shearing injury to the nerve; (2) a direct traction injury due to the nerve stretching against the posterior petroclinoid ligament at the base of the oculomotor triangle secondary to the downward displacement of the brainstem at the time of impact; (3) a direct vascular compression as a result of internal carotid artery (ICA) dissection or pseudoaneurysm; (4) an indirect injury caused by impaired blood supply to the third nerve in addition to the detrimental biochemical effects of the underlying brain injury itself. Understanding the exact mechanism underlying the onset of 3cnP is key to provide an informed clinical decision-making to the patients and ensure their best chances of recovery. Our experience corroborates data from the literature showing that, even in Grade III DAI, prompt recognition of isolated 3cnP can guide adequate treatment. Nonetheless, even when an overall good neurological outcome is achieved, recovery of isolated 3cnP is dismal, and only rarely the visual deficit completely resolves.
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Qi H, Li K. Civilian gunshot wounds to the head: a case report, clinical management, and literature review. Chin Neurosurg J 2021; 7:12. [PMID: 33531086 PMCID: PMC7856761 DOI: 10.1186/s41016-020-00227-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Civilian gunshot wounds to the head refer to brain injury caused by projectiles such as gun projectiles and various fragments generated by explosives in a power launch or explosion. Gunshot wounds to the head are the deadliest of all gun injuries. According to literature statistics, the survival rate of patients with gunshot wounds to the head is only 9%. Due to the strict management of various types of firearms, they rarely occur, so the injury mechanism, injury and trauma analysis, clinical management, and surgical standards are almost entirely based on military experience, and there are few related reports, especially of the head, in which an individual suffered a fatal blow more than once in a short time. We report a case with a return to almost complete recovery despite the patient suffering two gunshot injuries to the head in a short period of time. CASE PRESENTATIONS We present a case of a 53-year-old man who suffered two gunshot injuries to the head under unknown circumstances. On initial presentation, the patient had a Glasgow Coma Scale score of 6, was unable to communicate, and had loss of consciousness. The first bullet penetrated the right frontal area and finally reached the right occipital lobe. When the patient reflexively shielded his head with his hand, the second bullet passed through the patient's right palm bone, entered the right frontotemporal area, and came to rest deep in the lateral sulcus. The patient had a cerebral hernia when he was admitted to the hospital and immediately entered the operating room for rescue after a computed tomography scan. After two foreign body removals and skull repair, the patient recovered completely. CONCLUSIONS Gunshot wounds to the head have a high mortality rate and usually require aggressive management. Evaluation of most gunshot injuries requires extremely fast imaging examination upon arrival at the hospital, followed by proactive treatment against infection, seizure, and increased intracranial pressure. Surgical intervention is usually necessary, and its key points include the timing, method, and scope of the operation.
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Affiliation(s)
- Haoyi Qi
- Qinghai University, No. 251 Ningda Road, Xining, 810016 Qinghai Province China
| | - Kunzheng Li
- The Affiliated Hospital of Qinghai University, No. 29 Tongren Road, Xining, 810000 Qinghai Province China
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Graves WC, Oyesanya TO, Gormley M, Røe C, Andelic N, Seel RT, Lu J. Pre- and in-hospital mortality for moderate-to-severe traumatic brain injuries: an analysis of the National Trauma Data Bank (2008-2014). Brain Inj 2021; 35:265-274. [PMID: 33529087 DOI: 10.1080/02699052.2021.1873419] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives: This study aimed to: (1) evaluate pre- and in-hospital mortality for moderate-to-severe TBI in the U.S. by injury type (blunt vs. penetrating) and (2) estimate annual regression-adjusted mortality from 2008-2014.Methods: Data were analyzed from the National Trauma Data Bank (N=247,648). Multivariable logistic regression analyses were performed by injury type to assess changes in mortality between study periods (early period: 2008-2010; late period: 2011-2014) and to estimate annual regression-adjusted mortality. Mortality odds ratios and 95% confidence intervals were calculated.Results: Total observed mortality was 18.8%. After covariate adjustment, patients in the late period had an increased odds of prehospital mortality compared to patients in the early period for blunt (OR: 4.69; 95%CI: 4.41-4.98) and penetrating trauma (OR: 4.71; 95%CI: 4.39-5.06). In contrast, patients in the late period had a decreased odds of in-hospital mortality compared to patients in the early period for blunt (OR: 0.95; 95%CI: 0.91-0.98) and penetrating trauma (OR: 0.92; 95%CI: 0.85-0.98).Conclusions: The decreasing in-hospital mortality trend is consistent with previous literature. Additional research is warranted to validate the observed increase in prehospital mortality and to identify best practices that can improve prehospital outcomes for patients with moderate-to-severe TBI.
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Affiliation(s)
- Whitney C Graves
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
| | - Tolu O Oyesanya
- School of Nursing, Duke University, Durham, North Carolina, USA
| | - Mirinda Gormley
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
| | - Cecilie Røe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ronald T Seel
- Center for Rehabilitation Science and Engineering (CERSE) Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
| | - Juan Lu
- Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
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18
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Platt A, Collins J, Horowitz PM. Cranial Vault Reconstruction and Evacuation of Hemorrhage After a Bifrontal Gunshot Wound to the Brain. World Neurosurg 2020; 138:408-410. [PMID: 32247791 DOI: 10.1016/j.wneu.2020.03.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/22/2020] [Accepted: 03/23/2020] [Indexed: 11/29/2022]
Abstract
Civilian gunshot wounds to the brain are associated with high overall mortality; however, outcomes can vary significantly depending on bullet trajectory. This report details the outcome of a patient who sustained a bifrontal gunshot wound with multiple associated calvarial and frontal sinus fractures. Although surgery for penetrating brain injury is most frequently employed for relief of mass effect and decompression of vital structures, this case report describes a more comprehensive technique involving duroplasty, obliteration of the frontal sinus, and cranial vault reconstruction with the aim of decreasing the rate of cerebrospinal fluid leak, infection, reoperation, and readmission.
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Affiliation(s)
- Andrew Platt
- Department of Surgery, Section of Neurosurgery, University of Chicago, Chicago, Illinois, USA.
| | - John Collins
- Department of Radiology, University of Chicago, Chicago, Illinois, USA
| | - Peleg M Horowitz
- Department of Surgery, Section of Neurosurgery, University of Chicago, Chicago, Illinois, USA
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Loggini A, Vasenina VI, Mansour A, Das P, Horowitz PM, Goldenberg FD, Kramer C, Lazaridis C. Management of civilians with penetrating brain injury: A systematic review. J Crit Care 2020; 56:159-166. [DOI: 10.1016/j.jcrc.2019.12.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/05/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022]
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20
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Kim LH, Quon JL, Cage TA, Lee MB, Pham L, Singh H. Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: A decision-tree algorithm based on a single trauma center. J Clin Neurosci 2020; 75:71-79. [PMID: 32241644 DOI: 10.1016/j.jocn.2020.03.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/20/2020] [Indexed: 11/30/2022]
Abstract
Gunshot wounds (GSW) are one of the most lethal forms of head trauma. The lack of clear guidelines for civilian GSW complicates surgical management. We aimed to develop a decision-tree algorithm for mortality prediction and report long-term outcomes on survivors based on 15-year data from our level 1 trauma center. We retrospectively reviewed 96 consecutive patients who presented with cerebral GSWs between 2003 and 2018. Clinical information from our trauma database, EMR, and relevant imaging scans was reviewed. A decision-tree model was constructed based on variables showing significant differences between survivors and non-survivors. After excluding patients who died at arrival, 54 patients with radiologically confirmed intracranial injury were included. Compared to survivors (51.9%), non-survivors (48.1%) were significantly more likely to have perforating (entry and exit wound), as opposed to penetrating (entry wound only), injuries. Bi-hemispheric and posterior fossa involvement, cerebral herniation, and intraventricular hemorrhage were more commonly present in non-survivors. Based on the decision-tree, Glasgow Coma Scale (GCS) > 8 and penetrating, uni-hemispheric injury predicted survival. Among patients with GCS ≤ 8 and normal pupillary response, lack of 1) posterior fossa involvement, 2) cerebral herniation, 3) bi-hemispheric injury, and 4) intraventricular hemorrhage, were associated with survival. Favorable long-term outcomes (mean follow-up 34.4 months) were possible for survivors who required neurosurgery and stable patients who were conservatively managed. We applied clinical and radiological characteristics that predicted survival to construct a decision-tree to facilitate surgical decision-making for GSW. Further validation of the algorithm in a large patient setting is recommended.
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Affiliation(s)
- Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Jennifer L Quon
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Tene A Cage
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Marco B Lee
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Lan Pham
- Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA.
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Lindfors M, Lindblad C, Nelson DW, Bellander BM, Siironen J, Raj R, Thelin EP. Prognostic performance of computerized tomography scoring systems in civilian penetrating traumatic brain injury: an observational study. Acta Neurochir (Wien) 2019; 161:2467-2478. [PMID: 31659439 PMCID: PMC6874621 DOI: 10.1007/s00701-019-04074-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/13/2019] [Indexed: 01/21/2023]
Abstract
Background The prognosis of penetrating traumatic brain injury (pTBI) is poor yet highly variable. Current computerized tomography (CT) severity scores are commonly not used for pTBI prognostication but may provide important clinical information in these cohorts. Methods All consecutive pTBI patients from two large neurotrauma databases (Helsinki 1999–2015, Stockholm 2005–2014) were included. Outcome measures were 6-month mortality and unfavorable outcome (Glasgow Outcome Scale 1–3). Admission head CT scans were assessed according to the following: Marshall CT classification, Rotterdam CT score, Stockholm CT score, and Helsinki CT score. The discrimination (area under the receiver operating curve, AUC) and explanatory variance (pseudo-R2) of the CT scores were assessed individually and in addition to a base model including age, motor response, and pupil responsiveness. Results Altogether, 75 patients were included. Overall 6-month mortality and unfavorable outcome were 45% and 61% for all patients, and 31% and 51% for actively treated patients. The CT scores’ AUCs and pseudo-R2s varied between 0.77–0.90 and 0.35–0.60 for mortality prediction and between 0.85–0.89 and 0.50–0.57 for unfavorable outcome prediction. The base model showed excellent performance for mortality (AUC 0.94, pseudo-R2 0.71) and unfavorable outcome (AUC 0.89, pseudo-R2 0.53) prediction. None of the CT scores increased the base model’s AUC (p > 0.05) yet increased its pseudo-R2 (0.09–0.15) for unfavorable outcome prediction. Conclusion Existing head CT scores demonstrate good-to-excellent performance in 6-month outcome prediction in pTBI patients. However, they do not add independent information to known outcome predictors, indicating that a unique score capturing the intracranial severity in pTBI may be warranted. Electronic supplementary material The online version of this article (10.1007/s00701-019-04074-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matias Lindfors
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029, Helsinki, Finland.
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David W Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Theme Neuro, Karolinska University Hospital, Stockholm, Sweden
| | - Jari Siironen
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029, Helsinki, Finland
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- Theme Neuro, Karolinska University Hospital, Stockholm, Sweden
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Tunthanathip T, Udomwitthayaphiban S. Development and Validation of a Nomogram for Predicting the Mortality after Penetrating Traumatic Brain Injury. Bull Emerg Trauma 2019; 7:347-354. [PMID: 31857996 PMCID: PMC6911715 DOI: 10.29252/beat-070402] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Objective: To determine the factors associated with mortality in penetrating brain injury (PTBI) and proposed the nomogram predicting the risk of death. Methods: A retrospective cohort study was conducted on all patients who had sustained PTBI between 2009 and 2018. Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Prognostic factors analysis was conducted using a forest plot. Therefore, the nomogram was developed and validated. For the propose of evaluation, the nomogram’s sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Receiver Operating Characteristic (ROC) curve and the area under the receiver operating characteristic (AUC) were determined for validating the optimal cut-off point of the total scores. Results: During the study period, 62 individuals enrolled. In the univariate analysis, factors associated with the morality were normal pupils’ reactivity to light (OR 0.04, p < 0.001), hypotension (OR 9.91, p<0.001), hypoxia (OR 10.2, p=0.04), bihemispheric injuries (OR 19.0, p=0.001), multilobar injuries (OR 21.5, p< 0.001), subarachnoid hemorrhage (OR 6.9, p= 0.02), intraventricular hemorrhage (OR 26.6, p= 0.006), basal cistern effacement (OR 28.8, , p<0.001), midline shift >5 mm (OR 0.19, p<0.001) were significantly associated with death. In multivariable analysis, hypotension (OR 8.82, p=0.03), normal pupils’ reactivity to light (OR 0.07, p =0.01), midline shift >5 mm (OR 18.23, p<0.007) were significantly associated with death. The nomogram’s sensitivity, specificity, PPV, NPV, and AUC for predicting mortality (total score ≥ 100) were 80%, 92.6%, 72.7%, 95.0%, and, 0.86 respectively. Conclusions: PTBI is the fatal injury depend on both clinical and neuroimaging parameters. The nomogram is the alternative method providing prognostic parameters toward implication for clinical decision making.
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Affiliation(s)
- Thara Tunthanathip
- Division of Neurological Surgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkla, Thailand
| | - Suphak Udomwitthayaphiban
- Division of Neurological Surgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkla, Thailand
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Frösen J, Frisk O, Raj R, Hernesniemi J, Tukiainen E, Barner-Rasmussen I. Outcome and rational management of civilian gunshot injuries to the brain-retrospective analysis of patients treated at the Helsinki University Hospital from 2000 to 2012. Acta Neurochir (Wien) 2019; 161:1285-1295. [PMID: 31129782 PMCID: PMC6581925 DOI: 10.1007/s00701-019-03952-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/08/2019] [Indexed: 11/25/2022]
Abstract
Background Treatment of gunshot wounds of the brain (GSWB) remains controversial and there is high variation in reported survival rates (from < 10 to > 90%) depending on the etiology and country. We retrospectively analyzed the outcome of a series of consecutive GSWB patients admitted alive to a level 1 trauma center in a safe high-income welfare country with a low rate of homicidal gun violence. Methods Patients admitted due to a GSWB to the HUS Helsinki University Hospital during 2000–2012 were identified from hospital discharge registry and log books of the emergency room and ICU. CT scans and medical records of these patients were reviewed. Univariate analysis and backward logistic regression were performed, and their results compared with that of a systematic literature review of factors related to the outcome of GSWB patients. Results Sixty-four patients admitted alive after GSWB were identified. Eighty percent had self-inflicted GSWB, 81% were contact shots, and 70% were caused by handguns. In-hospital mortality was 72%. Factors associated with mortality in our series were low GCS (≤ 8) at admission, transventricular bullet trajectory, and associated damage to deep brain structures, as reported before in the literature. Of the 64 patients admitted alive, 42% (27/64) were admitted to ICU, 34% (22/64) underwent surgery, and in 25% (16/64), craniotomy and hematoma evacuation was performed. Mortality in the surgically treated group was 32% but near 100% without surgery and ICU treatment. Median GOS in the surgically treated patients was 3 (range 1–5). Conclusions GSWB caused by contact shot from handguns has a high mortality rate, but can be survived with reasonable outcome if limited to lobar injury without significant damage to deep brain structures or brain stem. In such GSWB patients, initial aggressive resuscitation, ICU admission, and surgery seem indicated. Electronic supplementary material The online version of this article (10.1007/s00701-019-03952-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juhana Frösen
- Department of Neurosurgery, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.
| | - Oskari Frisk
- Department of Plastic Surgery, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha Hernesniemi
- Juha Hernesniemi International Center for Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Erkki Tukiainen
- Department of Plastic Surgery, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ian Barner-Rasmussen
- Department of Plastic Surgery, HUS Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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