The diagnosis and surgical treatment of central brain herniations caused by traumatic bifrontal contusions

Demographics, presentation, and clinical outcomes after traumatic bifrontal contusions: a systematic review

Traumatic bifrontal contusions (TBC) form a recognised clinical entity among patients with traumatic brain injury (TBI). This study aims to systematically review current literature on demographics, management, and predictors of outcomes of patients with TBC. A multi-database literature search (PubMed, Cochrane, OVID Medline/Embase) was performed using PRISMA as a search strategy. Studies were selected by predefined selection criteria (PROSPERO: CRD42018055390), and risk of bias was assessed using an adapted form of ROBINS-I tool. Of the 275 studies yielded by the literature search, seven articles met the criteria for inclusion, all of which were level III evidence. Total cohort consisted of 468 patients; predominantly male (n = 5; 303/417 patients) with average age 44.3 years (range, 7–81). Falls (44.9%) and road traffic accidents (46.6%) were the commonest mechanisms of injury with an average presentation GCS of 9.2 (n = 3, 119 patients). GCS on admission of ≤ 13.1 and contusion volume at day 2 post-injury of ≥ 62.9cm³ were associated with increased risk of deterioration needing surgical interventions (n = 1, 7 patients). The majority of patients underwent surgery; the average GOS was 4, at an average follow-up duration of 11.7 months (n = 6, 356 patients). The currently available evidence on the management of TBC is scarce. Larger multicentre well-designed studies are needed to further delineate the factors behind acute deterioration, the effectiveness of management options. Once in place, this can be used to develop and test an algorithmic approach to management of TBC resulting in consistently improved outcomes.

Application of a Grading System in the Treatment of Frontal Lobe Contusion in High-Altitude Regions

OBJECTIVE

With the development of frontal contusion, patients may rapidly deteriorate or even die. Experience in the treatment of frontal contusion in high-altitude regions is limited; thus, we explore a grading system for the treatment of frontal lobe contusion.

METHODS

A total of 446 patients with frontal contusions in a high-altitude regions were reviewed retrospectively. We combined the patients' computed tomography scans of the head and clinical features for grading. The score determined the treatment and whether the bone flap was removed. If the patient's condition deteriorated, and the score was greater than 1, the patient was treated surgically. At the same time, the risk factors of deterioration were analyzed. Finally, the Glasgow Outcome Scale of conservative treatment and surgical treatment groups was analyzed.

RESULTS

Among the 446 patients, 254 were conservatively treated, and 28 worsened and underwent surgical treatment. In total, 122 patients received an operation. Logistic regression analysis indicated that scattered hematoma, anterior angle of the ventricle, and hemoglobin concentration were risk factors. The postoperative Glasgow Outcome Scale of conservative treatment and surgical treatment groups was analyzed; the good healing rate of the conservative treatment group was 91.12%, the good healing rate of the retain-bone flap surgical group was 75%, and the good healing rate of the remove-bone flap surgical group was 63.33%. The failure rates of the groups were 9.38% and 7.78%, respectively.

CONCLUSIONS

This grading system could guide frontal contusion treatment, which could help patients to achieve a good healing rate and reduce the failure rate.

Clinical application of the supraorbital key-hole approach to the treatment of unilateral-dominant bilateral frontal contusions

We compared the surgical efficacy of the supraorbital key-hole approach (SKA) to conventional unilateral frontotemporal craniotomy (UFTC) for the treatment of patients with unilateral-dominant bilateral frontal contusions (BFCs). A retrospective analysis of 62 patients with unilateral-dominant BFCs who underwent surgery at our institute between 2014 and 2017 was performed. There were 26 patients who underwent SKA (group A) and 36 who underwent UFTC (group B). Postoperative computed tomography scans showed satisfactory evacuation of the frontal cerebral contusions in both groups (p > 0.05). There was less intraoperative blood loss in group A than group B (17.1 ± 4.55 vs. 67.6 ± 10.28 mL, p < 0.05). The operative time was also shorter in group A (82.7 ± 13.73 vs. 132.4 ± 9.17 min, p < 0.05). Postoperative bleeding occurred in three cases in group A and in only one case in group B (p > 0.05). The average length of hospitalization was shorter in group A than group B (7.3 ± 1.09 vs. 12.9 ± 1.71 days, p < 0.05). No differences in the Glasgow Outcome Scale were observed between the two groups after 6 months of follow-up (p > 0.05). Thus, compared to UFTC, SKA is associated with shorter operation times and less trauma to the surrounding brain tissue.

Cardiac troponin and cerebral herniation in acute intracerebral hemorrhage

OBJECTIVES

To explore the association, if any, between the relationship between cardiac troponin and cerebral herniation after intracerebral hemorrhage (ICH).

METHODS

Six hundred and eighty-seven consecutive ICH patients admitted to West China Hospital from May 1, 2014 to September 1, 2015 were retrospectively reviewed. Data on demographics, etiology, laboratory examinations at admission including serum cardiac troponin, computed tomography (CT) scans at admission and follow-up, and clinical outcomes were obtained. Using multiple logistic regression to identify the relationship of troponin and herniation. The association between troponin and hematoma volume was assessed using bivariate correlation and linear regression.

RESULTS

Among 188 (27.4%) patients who underwent the test of serum cardiac troponin at admission, 16 (8.5%) demonstrated cerebral herniation. The median time from symptom onset to CT at admission and follow-up was 4 and 30.25 hr, respectively. In multivariate analysis, elevated troponin was independently associated with cerebral herniation (adjusted odds ratio [OR] 5.19; 95% confidence interval [CI], 1.08-24.93). And those with elevated troponin had larger hematoma volume at follow-up in bivariate correlation (correlation coefficient, .375, p = .003) and linear regression (β, .370, 95% CI, 0.062-0.320, p = .005), higher National Institutes of Health Stroke Scale score (adjusted OR 2.06; 95% CI, 1.06-4.01, p = .033) and lower Glasgow Coma Scale score (adjusted OR 2.34; 95% CI, 1.17-4.68, p = .016) than those without.

CONCLUSIONS

Elevated cardiac troponin was associated with an almost five-fold increased risk of cerebral herniation, but not in-hospital mortality. The possibility of cerebral herniation should be considered when ICH patients with large hematoma volume and elevated troponin.

Technique of ICP Monitored Stepwise Intracranial Decompression Effectively Reduces Postoperative Complications of Severe Bifrontal Contusion

Background

Bifrontal contusion is a common clinical brain injury. In the early stage, it is often mild, but it progresses rapidly and frequently worsens suddenly. This condition can become life threatening and therefore requires surgery. Conventional decompression craniectomy is the commonly used treatment method. In this study, the effect of intracranial pressure (ICP) monitored stepwise intracranial decompression surgery on the prognosis of patients with acute severe bifrontal contusion was investigated.

Method

A total of 136 patients with severe bifrontal contusion combined with deteriorated intracranial hypertension admitted from March 2001 to March 2014 in our hospital were selected and randomly divided into two groups, i.e., a conventional decompression group and an ICP monitored stepwise intracranial decompression group (68 patients each), to conduct a retrospective study. The incidence rates of acute intraoperative encephalocele, delayed hematomas, and postoperative cerebral infarctions and the Glasgow outcome scores (GOSs) 6 months after the surgery were compared between the two groups.

Results

(1) The incidence rates of acute encephalocele and contralateral delayed epidural hematoma in the stepwise decompression surgery group were significantly lower than those in the conventional decompression group; the differences were statistically significant (P < 0.05); (2) 6 months after the surgery, the incidence of vegetative state and mortality in the stepwise decompression group were significantly lower than those in the conventional decompression group (P < 0.05); the rate of favorable prognosis in the stepwise decompression group was also significantly higher than that in the conventional decompression group (P < 0.05).

Conclusion

The ICP monitored stepwise intracranial decompression technique reduced the perioperative complications of traumatic brain injury through the gradual release of ICP and was beneficial to the prognosis of severe traumatic brain injury treatment.