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Schröder I, Güresir E, Vatter H, Soehle M. Single-centre real-life observational study on mortality and outcomes: decompressive craniectomy and brain death in traumatic brain injury, haemorrhage, and other cerebral diseases. Acta Neurochir (Wien) 2024; 166:283. [PMID: 38969875 PMCID: PMC11226498 DOI: 10.1007/s00701-024-06170-3] [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: 03/13/2024] [Accepted: 06/12/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is used after severe brain damages with elevated, refractory intracranial pressure (ICP). In a non age-restricted population, mortality rates and long-term outcomes following DHC are still unclear. This study's objectives were to examine both, as well as to identify predictors of unfavourable outcomes. METHODS We undertook a retrospective observational analysis of patients aged 18 years and older who underwent DHC at the University Hospital of Bonn between 2018 and 2020, due to traumatic brain injury (TBI), haemorrhage, tumours or infections. Patient outcomes were assessed by conducting telephone interviews, utilising questionnaires for modified Rankin Scale (mRS) and extended Glasgow Outcome scale (GOSE). We evaluated the health-related quality of life using the EuroQol (EQ-5D-5L) scale. RESULTS A total of 144 patients with a median age of 58.5 years (range: 18 to 85 years) were evaluated. The mortality rate was 67%, with patients passing away at a median of 6.0 days (IQR [1.9-37.6]) after DHC. Favourable outcomes, as assessed by the mRS and GOSE were observed in 10.4% and 6.3% of patients, respectively. Cox regression analysis revealed a 2.0% increase in the mortality risk for every year of age (HR = 1.017; 95% CI [1.01-1.03]; p = 0.004). Uni- and bilateral fixed pupils were associated with a 1.72 (95% CI [1.03-2.87]; p = 0.037) and 3.97 (95% CI [2.44-6.46]; p < 0.001) times higher mortality risk, respectively. ROC-analysis demonstrated that age and pupillary reactivity predicted 6-month mortality with an AUC of 0.77 (95% CI [0.69-0.84]). The only parameter significantly associated with a better quality of life was younger age. CONCLUSIONS Following DHC, mortality remains substantial, and favourable outcomes occur rarely. Particularly in elderly patients and in the presence of clinical signs of herniation, mortality rates are notably elevated. Hence, the indication for DHC should be set critically.
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Affiliation(s)
- Isabelle Schröder
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Martin Soehle
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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Englbrecht JS, Bajohr C, Zarbock A, Stummer W, Holling M. A ten-year retrospective analysis of decompressive craniectomy or craniotomy after severe brain injury and its implications for donation after brain death. Sci Rep 2024; 14:15233. [PMID: 38956393 PMCID: PMC11219913 DOI: 10.1038/s41598-024-66129-3] [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: 03/19/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024] Open
Abstract
Craniotomy or decompressive craniectomy are among the therapeutic options to prevent or treat secondary damage after severe brain injury. The choice of procedure depends, among other things, on the type and severity of the initial injury. It remains controversial whether both procedures influence the neurological outcome differently. Thus, estimating the risk of brain herniation and death and consequently potential organ donation remains difficult. All patients at the University Hospital Münster for whom an isolated craniotomy or decompressive craniectomy was performed as a treatment after severe brain injury between 2013 and 2022 were retrospectively included. Proportion of survivors and deceased were evaluated. Deceased were further analyzed regarding anticoagulants, comorbidities, type of brain injury, potential and utilized donation after brain death. 595 patients were identified, 296 patients survived, and 299 deceased. Proportion of decompressive craniectomy was higher than craniotomy in survivors (89% vs. 11%, p < 0.001). Brain death was diagnosed in 12 deceased and 10 donations were utilized. Utilized donations were comparable after both procedures (5% vs. 2%, p = 0.194). Preserved brain stem reflexes as a reason against donation did not differ between decompressive craniectomy or craniotomy (32% vs. 29%, p = 0.470). Patients with severe brain injury were more likely to survive after decompressive craniectomy than craniotomy. Among the deceased, potential and utilized donations did not differ between both procedures. This suggests that brain death can occur independent of the previous neurosurgical procedure and that organ donation should always be considered in end-of-life decisions for patients with a fatal prognosis.
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Affiliation(s)
- Jan Sönke Englbrecht
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
| | - Charis Bajohr
- Department of Anesthesiology, Herz-Jesu-Hospital Münster-Hiltrup, Münster, Germany
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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ElSaban M, Bhatt G, Lee J, Koshiya H, Mansoor T, Amal T, Kashyap R. A historical delve into neurotrauma-focused critical care. Wien Med Wochenschr 2023; 173:368-373. [PMID: 36729341 PMCID: PMC9892675 DOI: 10.1007/s10354-022-01002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/27/2022] [Indexed: 02/03/2023]
Abstract
Neurocritical care is a multidisciplinary field managing patients with a wide range of aliments. Specifically, neurotrauma is a rapidly growing field with increasing demands. The history of how neurotrauma management came to its current form has not been extensively explored before. Our review delves into the history, timeline, and noteworthy pioneers of neurotrauma-focused neurocritical care. We explore the historical development during early times, the 18th-20th centuries, and modern times, as well as warfare- and sports-related concussions. Research is ever growing in this budding field, with several promising innovations on the horizon.
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Affiliation(s)
- Mariam ElSaban
- Department of Anesthesiology, Mayo Clinic, Rochester, MN USA
| | - Gaurang Bhatt
- All India Institute of Medical Sciences, Rishikesh, India
| | - Joanna Lee
- David Tvildiani Medical University, Tbilisi, Georgia
| | - Hiren Koshiya
- Department of Hematology & Oncology, Mayo Clinic, Jacksonville, USA Florida
| | | | - Tanya Amal
- Maulana Azad Medical College, New Delhi, India
| | - Rahul Kashyap
- Department of Critical Care Medicine, Mayo Clinic, Rochester, MN USA
- Medical director research, WellSpan Health, New York, PA USA
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Endicott L, Ehresman J, Tettelbach W, Forsyth A, Lee BS. Dehydrated human amnion/chorion membrane use in emergent craniectomies shows minimal dural adhesions. J Wound Care 2023; 32:634-640. [PMID: 37830838 DOI: 10.12968/jowc.2023.32.10.634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Decompressive craniectomies (DCs) are routinely performed neurosurgical procedures to emergently treat increased intracranial pressure secondary to multiple aetiologies, such as subdural haematoma, epidural haematoma, or malignant oedema in the setting of acute infarction. The DC procedure typically induces epidural fibrosis post-cranial resection, resulting in adherence of the dura to both the brain internally and skin flap externally. This becomes especially problematic in the setting of skull flap replacement for cranioplasty as adherences can lead to bridging vein tear, damage to the underlying brain cortex, and other postoperative complications. Dural adjuvants, which can contribute to decreased rate of adherence formation, can thereby reduce both postoperative cranioplasty complications and operative duration. Dehydrated human amnion/chorion membrane (DHACM) allografts (AMNIOFIX, MIMEDX Group Inc., US) have been shown to reduce the rate of dural scar tissue formation in re-exploration of posterior lumbar interbody fusion operations which require entry into the epidural space. The purpose of this study was to evaluate whether or not the use of DHACM in the setting of emergent craniectomies decreased the rate of dural adhesion formation and subsequent cranioplasty complications. Patients (n=7) who underwent emergent craniectomy and intraoperative placement of DHACM were evaluated during replacement of either an autologous skull cap or a custom-made implant, at which point the degree of adhesions was qualitatively assessed. Placement of DHACM below and on top of the dura resulted in negligible adhesion being found during the defect exposure, and there were no intraoperative complications during cranioplasties. Reported estimated blood loss across the seven patients averaged 64.2ml, total operative time averaged 79.2 minutes, and time dedicated to exposing defect for bone flap placement was <3 minutes.
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Affiliation(s)
- Luke Endicott
- Arizona College of Osteopathic Medicine, Glendale, AZ, US
| | - Jeff Ehresman
- Barrow Neurosurgical Institute, Department of Neurosurgery, Phoenix, AZ, US
| | - William Tettelbach
- Duke University School of Medicine, Department of Anesthesiology, Durham, NC, US
- American Professional Wound Care Association, LA, US
- Association for the Advancement of Wound Care, WI, US
- HCA Healthcare, Mountain Division, Salt Lake City, UT, US
- Western University of Health Sciences, College of Podiatric Medicine, Pomona, CA, US
- MIMEDX Group, Inc., Marietta, GA, US
| | - Allyn Forsyth
- MIMEDX Group, Inc., Marietta, GA, US
- Department of Biology, San Diego State University, San Diego, CA, US
| | - Bryan S Lee
- Barrow Neurosurgical Institute, Department of Neurosurgery, Phoenix, AZ, US
- HonorHealth Neuroscience Research Institute, Phoenix, AZ, US
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Zheng J, Zhang C, Wu Y, Zhang C, Che Y, Zhang W, Yang Y, Zhu J, Yang L, Wang Y. Controlled Decompression Alleviates Motor Dysfunction by Regulating Microglial Polarization via the HIF-1α Signaling Pathway in Intracranial Hypertension. Mol Neurobiol 2023; 60:5607-5623. [PMID: 37328678 DOI: 10.1007/s12035-023-03416-6] [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: 01/25/2023] [Accepted: 05/24/2023] [Indexed: 06/18/2023]
Abstract
Decompressive craniectomy (DC) is a major form of surgery that is used to reduce intracranial hypertension (IH), the most frequent cause of death and disability following severe traumatic brain injury (sTBI) and stroke. Our previous research showed that controlled decompression (CDC) was more effective than rapid decompression (RDC) with regard to reducing the incidence of complications and improving outcomes after sTBI; however, the specific mechanisms involved have yet to be elucidated. In the present study, we investigated the effects of CDC in regulating inflammation after IH and attempted to identify the mechanisms involved. Analysis showed that CDC was more effective than RDC in alleviating motor dysfunction and neuronal death in a rat model of traumatic intracranial hypertension (TIH) created by epidural balloon pressurization. Moreover, RDC induced M1 microglia polarization and the release of pro-inflammatory cytokines. However, CDC treatment resulted in microglia primarily polarizing into the M2 phenotype and induced the significant release of anti-inflammatory cytokines. Mechanistically, the establishment of the TIH model led to the increased expression of hypoxia-inducible factor-1α (HIF-1α); CDC ameliorated cerebral hypoxia and reduced the expression of HIF-1α. In addition, 2-methoxyestradiol (2-ME2), a specific inhibitor of HIF-1α, significantly attenuated RDC-induced inflammation and improved motor function by promoting M1 to M2 phenotype transformation in microglial and enhancing the release of anti-inflammatory cytokines. However, dimethyloxaloylglycine (DMOG), an agonist of HIF-1α, abrogated the protective effects of CDC treatment by suppressing M2 microglia polarization and the release of anti-inflammatory cytokines. Collectively, our results indicated that CDC effectively alleviated IH-induced inflammation, neuronal death, and motor dysfunction by regulating HIF-1α-mediated microglial phenotype polarization. Our findings provide a better understanding of the mechanisms that underlie the protective effects of CDC and promote clinical translational research for HIF-1α in IH.
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Affiliation(s)
- Jie Zheng
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Chenxu Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Yonghui Wu
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Chonghui Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Yuanyuan Che
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Wang Zhang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Yang Yang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China
| | - Jie Zhu
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China.
| | - Likun Yang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China.
| | - Yuhai Wang
- Department of Neurosurgery, The 904th Hospital of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, 214044, Jiangsu, China.
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Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. Neurologia 2023:S2173-5808(23)00008-1. [PMID: 37031799 DOI: 10.1016/j.nrleng.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 08/04/2020] [Indexed: 04/11/2023] Open
Abstract
INTRODUCTION Increased intracranial pressure (ICP) has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury (TBI). Traditionally, ICP-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe TBI in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.
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Affiliation(s)
- César E Escamilla-Ocañas
- Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA.
| | - Nadxielli Albores-Ibarra
- División de Ciencias de la Salud, Universidad de Monterrey, San Pedro Garza García, Nuevo León, México
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Cunan ET, Dudley RWR, Shemie SD. Delayed recovery from severe refractory intracranial hypertension due to expansion of skin and pericranium stretch after decompressive craniectomy. Can J Anaesth 2023; 70:796-801. [PMID: 37131036 DOI: 10.1007/s12630-023-02429-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/22/2023] [Accepted: 01/22/2023] [Indexed: 05/04/2023] Open
Abstract
PURPOSE Decompressive craniectomy immediately reduces intracranial pressure by increasing space to accommodate brain volumes. Any delay in reduction of pressure and signs of severe intracranial hypertension requires explanation. CLINICAL FEATURES We present the case of a 13-yr-old boy presenting with a ruptured arteriovenous malformation resulting in a massive occipito-parietal hematoma and increased intracranial pressure (ICP) refractory to medical management. This patient ultimately underwent a decompressive craniectomy (DC) for alleviation of increased ICP, despite which the patient's hemorrhage continued to worsen to the point of brainstem areflexia suggestive of possible progression to brain death. Within hours of the decompressive craniectomy, the patient displayed a relatively sudden, marked improvement in clinical status, most notably a return in pupillary reactivity and significant decrease in measured ICP. A review of postoperative images after the decompressive craniectomy suggested increases in brain volume that continued beyond the initial postoperative period. CONCLUSION We urge caution to be taken in the interpretation of the neurologic examination and measured ICP in the context of a decompressive craniectomy. In the patient described in this Case Report, we propose that ongoing expansion of brain volume following a decompressive craniectomy beyond the initial postoperative period, possibly secondary to the stretch of skin or pericranium (used as a dural substitute for expansile duraplasty), can explain further clinical improvements beyond the initial postoperative period. We call for routine serial analyses of brain volumes after decompressive craniectomy to confirm these findings.
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Affiliation(s)
- Ellery T Cunan
- Division of Pediatric Critical Care, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Roy W R Dudley
- Division of Pediatric Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Sam D Shemie
- Division of Pediatric Critical Care, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
- McGill University Health Centre Research Institute, 1001 Décarie Blvd., Montreal, QC, H4A 3J1, Canada.
- System Development/Deceased Donation, Canadian Blood Services, Ottawa, ON, Canada.
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Heck C. Decompressive Hemicraniectomy in the Stroke Patient. Crit Care Nurs Clin North Am 2023; 35:67-81. [PMID: 36774008 DOI: 10.1016/j.cnc.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Decompressive hemicraniectomy (DHC) is a life-saving procedure involving removal of large portions of the skull to relieve intracranial pressure in patients with space occupying cerebral edema such as traumatic brain injury (TBI) and stroke. Although the procedure has been shown to decrease mortality in patients, the risk of severe disability is significant. Quality of life, not just survival, following DHC has emerged as an important consideration when the decision is made to perform a DHC.
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Affiliation(s)
- Carey Heck
- Adult-Gerontology Acute Care Nurse Practitioner Program, Thomas Jefferson University, 901 Walnut Street, Suite 815, Philadelphia, PA 19107, USA.
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Muacevic A, Adler JR, Dighe O, Iratwar S, Bisen G. Decompressive Craniectomy in the Management of Low Glasgow Coma Score Patients With Extradural Hematoma: A Review of Literature and Guidelines. Cureus 2023; 15:e33790. [PMID: 36819419 PMCID: PMC9927871 DOI: 10.7759/cureus.33790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/15/2023] [Indexed: 01/16/2023] Open
Abstract
An extradural hematoma (EDH), also known as an epidural hematoma, is a collection of blood between the inner skull table and the dura mater. It is restricted by the coronal, lambdoid, and sagittal sutures, as these are dural insertions. EDH most frequently occurs in 10- to 40-year-old patients. EDH is uncommon after age 60, as dura matter adheres firmly to the inner skull table. EDH is more common among men as compared to women. EDH most commonly occurs in the temporo-frontal regions and can also be seen in the parieto-occipital, parasagittal regions, and middle and posterior fossae. An EDH contributes approximately 2% of total head injuries and 15% of total fatal head injuries. In EDH, patients typically have a persistent, severe headache, and also, following a few hours of injury, they gradually lose consciousness. The primary bleeding vessels for EDH are the middle meningeal artery, middle meningeal vein, and torn dural venous sinuses. EDH is one of the many consequences of severe traumatic brain injuries that might lead to death. EDH is potentially a lethal condition that requires immediate intervention as, if left untreated, it can lead to growing transtentorial herniation, diminished consciousness, dilated pupils, and other neurological problems. Non-contrast computed tomography (NCCT) imaging is the gold standard of investigation for diagnosing EDH. For patients with surgical indications, early craniotomy and evacuation of acute extradural hematoma (AEDH) is the gold standard procedure and is predicted to have significant clinical results. Nevertheless, there is an ongoing debate regarding the best surgical operations for AEDH. Neurosurgeons must choose between a decompressive craniectomy (DC) or a craniotomy to manage EDH, especially in patients with low Glasgow coma scores, to have a better prognosis and clinical results. This is a consultant-based review article in which we have tried to contemplate various pieces of available literature. Here, the objective is to hypothesize DC as the primary surgical management for massive hematoma, which usually presents as a low Glasgow coma score. This is because DC was found to be beneficial in clinical practice.
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Hakiki B, Liuzzi P, Pansini G, Pancani S, Romoli A, Draghi F, Orlandini S, Mannini A, Della Puppa A, Macchi C, Cecchi F. Impact of decompressive craniectomy on functional outcome of severe acquired brain injuries patients, at discharge from intensive inpatient rehabilitation. Disabil Rehabil 2022; 44:8375-8381. [PMID: 34928755 DOI: 10.1080/09638288.2021.2015461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE Decompressive craniectomy (DC) is a life-saving procedure conducted to treat refractory intracranial hypertension. Although DC reduces mortality of severe Acquired Brain Injury (sABI) survivors, it has been associated with severe long-term disability. This observational study compares functional outcomes at discharge from an Intensive Rehabilitative Unit (IRU) between sABI patients with and without DC. MATERIAL AND METHODS sABI patients undergoing DC before entering the Don Gnocchi Foundation IRU were compared with a group of sABI patients who did not undergo DC (No-DC group), after matching it by age, sex, aetiology, time post-onset, and clinical status. Inclusion criteria were: diagnosis of sABI, age 18+, time from the event <90 days. RESULTS A total of 87 (DC: 47) patients were included (median age: 60.5 [IQR = 17.47]). The two groups did not differ for admission clinical features except for the tracheostomy presence (more frequent in DC, p < 0.001). No significant differences were also found at discharge. DC group presented a significantly longer length-of-stay than No-DC group (p < 0.001) and a longer time to tracheostomy removal (p = 0.036). DC was not found to influence outcomes as consciousness improvement, tracheostomy removal, oral intake and functional independence. CONCLUSIONS sABI patients with DC improved after rehabilitation as much as No-DC patients did but they required a longer stay.Implications for RehabilitationDecompressive craniectomy (DC) is practiced during the acute phase after hemorrhagic, ischemic, traumatic severe brain injury as a life-saving procedure to treat refractory intracranial hypertensionDC has been associated with follow-up severe long-term disability, but no study yet addressed whether DC may affect intensive rehabilitation outcomes.Undergoing a DC is not a negative prognostic factor for achieving rehabilitation goals after a severe acquired brain injuryDC must be taken into account when customizing rehabilitation pathway especially because these patients required a longer time to reach the outcomes.
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Affiliation(s)
- Bahia Hakiki
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Piergiuseppe Liuzzi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,The BioRobotics Institute, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio 34, Pontedera (Pi), Italy
| | - Gastone Pansini
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Silvia Pancani
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Annamaria Romoli
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Francesca Draghi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy
| | - Simone Orlandini
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Andrea Mannini
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,The BioRobotics Institute, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio 34, Pontedera (Pi), Italy
| | - Alessandro Della Puppa
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Claudio Macchi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,Department of Experimental and Clinical Medicine, Università di Firenze, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
| | - Francesca Cecchi
- IRCCS Fondazione Don Carlo Gnocchi-ONLUS, Via di Scandicci 269, Florence (Fi), Italy.,Department of Experimental and Clinical Medicine, Università di Firenze, Largo Giovanni Alessandro Brambilla 3, Firenze (Fi), Italy
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11
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Caballero-Lozada AF, Miño-Bernal JF, Espinosa-Marsiglia RA, Rojas-Rincón V. Correlation between the Optic Nerve Sheath Diameter Measurement and Intracranial Hypertension Tomographic Findings from a Colombian Hospital. ARQUIVOS BRASILEIROS DE NEUROCIRURGIA: BRAZILIAN NEUROSURGERY 2022. [DOI: 10.1055/s-0041-1740174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Objective In the present study, we aimed at determining the correlation between tomographic findings of intracranial hypertension and ultrasound measurement of the optic nerve sheath diameter (ONSD).
Methods Observational, descriptive, prospective, cross-sectional pilot study. The present research was performed in a tertiary hospital in Cali, Colombia, from March 2019 to October 2019. Twenty-five patients constituted the intracranial hypertension group, and 25 patients without intracranial hypertension constituted the control group. Ultrasound measurements of the ONSD were assessed using a Sonosite Turbo (SonoSite Inc., Bothell, WA, USA) ultrasound. The computed tomography (CT) images obtained from each patient diagnosed with intracranial hypertension were available in the software of the hospital. The primary outcome was the ultrasound measurement of the ONSD.
Results The ONSD values of the right eye of the intracranial hypertension group ranged from 5.2 to 7.6 mm, and the ONSD of the left eye ranged from 5.3 to 7.3 mm. The global ONSD values, obtained from the average between the right and left eye, were recorded between 5.25 and 7.45 mm. Overall, our study indicated that ultrasound measurements of the ONSD were effective in differentiating a group with intracranial hypertension, previously diagnosed by CT scan images, from patients without this condition. According to the ROC curve, the optimal cutoff point for detecting intracranial hypertension was 5.2 mm.
Conclusions Ultrasound measurements of the ONSD correlated with the measurements obtained from CT scan images, suggesting that the ultrasound technique can be efficient in identifying patients with intracranial hypertension and valuable in cases when CT scan images are not an available option.
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Affiliation(s)
- Andrés Fabricio Caballero-Lozada
- Department of Anesthesiology and Resuscitation, Universidad del Valle, Cali, Colombia
- Department of Anesthesiology, Hospital Universitario del Valle, Cali, Colombia
- Fundación Hospital San José de Buga, Buga, Colombia
- Department of Anesthesiology, Unidad Central del Valle del Cauca, Tuluá, Colombia
| | | | - Rene Alberto Espinosa-Marsiglia
- Department of Anesthesiology and Resuscitation, Universidad del Valle, Cali, Colombia
- Department of Anesthesiology, Hospital Universitario del Valle, Cali, Colombia
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12
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Cunan ET, Dudley RWR, Shemie SD. In reply: Withholding therapeutic interventions in brain(stem) death: is it a self-fulfilling prophecy? Can J Anaesth 2022; 69:1439-1440. [PMID: 36097131 DOI: 10.1007/s12630-022-02326-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 10/14/2022] Open
Affiliation(s)
- Ellery T Cunan
- Department of Pediatrics, Division of Pediatric Critical Care, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Roy W R Dudley
- Department of Pediatric Surgery, Division of Pediatric Neurosurgery, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Sam D Shemie
- Department of Pediatrics, Division of Pediatric Critical Care, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
- MUHC Research Institute, Montreal, QC, Canada.
- Deceased Organ Donation, Canadian Blood Services, Ottawa, ON, Canada.
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13
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Yang J, Yang X, Wang J, Yu H, You C, Ma L, Guan J. Surgical technique of temporal muscle resuspension during cranioplasty for minimizing temporal hollowing: A case series. Front Surg 2022; 9:996484. [PMID: 36338643 PMCID: PMC9632970 DOI: 10.3389/fsurg.2022.996484] [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: 07/17/2022] [Accepted: 09/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background Temporal hollowing is a common but often overlooked complication following cranioplasty. To minimize temporal hollowing caused by temporal muscle contraction, we present the novel technique for temporal muscle resuspension during cranioplasty. Methods This is a retrospective case series which were done by a single surgeon at our university tertiary-A hospital between January 2019 and February 2020. The surgical technique was performed according to the forms of temporal muscle based on preoperative 3-D reconstruction and intraoperative images. All patients were followed up and evaluated on esthetic and functional outcomes. Results 17 patients with an average age of 39.35 years, frontotemporoparietal cranial defect size of 78.85 cm2, and median follow-up of 7 months were included. The main cause of decompressive craniectomy was trauma (n = 15). Techniques of temporal muscle augmentative resuspension were performed. The follow-up esthetic and functional outcome evaluation showed that all patients had good postoperative results. No revision surgery was found among the patients. Conclusions This study proposes methods of temporal muscle augmentative resuspension based on forms of the muscle. We believe this might be of use in minimizing temporal hollowing after cranioplasty.
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Affiliation(s)
- Jingguo Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyu Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Junjie Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hang Yu
- Sichuan Provincial People’s Hospital, University of Electronic Technology, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Junwen Guan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- Correspondence: Junwen Guan
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14
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Nerntengian N, Abboud T, Stepniewski A, Felmerer G, Rohde V, Tanrikulu L. Tissue Healing in Hemicraniectomy. Cureus 2022; 14:e29260. [PMID: 36133503 PMCID: PMC9482351 DOI: 10.7759/cureus.29260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Decompressive hemicraniectomy (DHC) is a last-resort treatment for refractory intracranial hypertension. Perioperative morbidity is associated with high risks of wound healing disturbances (WHD). Recently, a retromastoidal frontoparietooccipital (RMF) incision type was performed to avoid healing disturbance due to enhanced tissue flap perfusion compared to the classical reverse “question mark” (“Dandy flap”) incision. The goal of this study was to analyze the details of tissue healing problems in DHC. Materials and methods A total of 60 patients who underwent DHC were retrospectively analyzed. In 30 patients the “Dandy flap” incision (group A) and in 30 patients the RMF incision (group B) was made. Since no evidence-based data for the incision type that favors better wound healing exists, the form of incision was left at the surgeon´s discretion. Documentation of the patients was screened for the incidence of WHD: wound necrosis, dehiscence, and cerebrospinal fluid (CSF) leakage. Patient age, the time interval from surgery until the appearance of WHD, the length of surgeries in minutes, and the indications of the DHC were analyzed. A Chi-square test of independence was performed to examine the relationship between the incision type and the appearance of WHD with the statistical significance level set at p<0.05. The mean age of the patients, the mean time interval from surgery until the occurrence of WHD, and the mean length of the surgery between the two groups were compared using an independent sample t-test with the statistical significance level set at p<0.05. Results The most common indication for DHC in both groups was malignant MCA infarction (n=20, 66.6% for group A and n=16, 53.3% for group B). CSF leakage was 20% of the most frequent WHD in each group. Wound necrosis was observed only in group A. Although group B showed 13.3% fewer WHD than group A, this difference was not statistically significant. There was no statistically significant difference in the time range between surgery and the occurrence of WHD between the two groups. The length of surgery in group B was significantly shorter than in group A (120.2 mins vs. 103.7 mins). Conclusion A noticeable trend for reduced WHD was observed in the patient group using the RMF incision type although the difference was not statistically significant. We praise that the RMF incision allows an optimized skin-flap vascularization and, thereby, facilitates better wound healing. We were able to show a statistically shorter length of surgery with the RMF incision in contrast to the classic “Dandy flap” incision. Larger multicenter studies should be implemented to analyze and address the major advantages and pitfalls of the routinely applied incision techniques.
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15
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Cunan ET, Dudley R, Shemie SD. Decompressive craniectomy as a potentially reversible condition in brain death-brain stunning or skin and pericranium stretching? Can J Anaesth 2022; 69:811-814. [PMID: 35534771 DOI: 10.1007/s12630-022-02264-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022] Open
Affiliation(s)
- Ellery T Cunan
- Division of Pediatric Critical Care, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Roy Dudley
- Division of Pediatric Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Sam D Shemie
- MUHC Research Institute, Montreal, QC, Canada.
- Deceased Organ Donation, Canadian Blood Services, Ottawa, ON, Canada.
- Division of Pediatric Critical Care, Department of Pediatrics, Montreal Children's Hospital, McGill University, 1001 boulevard Décarie, B06.3834, Montreal, QC, H4A 3J1, Canada.
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16
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Wang G, Wang Z, Wen Y, Chen S, Li M, Zhang G, Yu H, Zhang S, Xu H, Qi S, Feng W. A preliminary report of one session treatment with cranioplasty and STA-MCA bypass for hemorrhagic MMD patients with skull defect. World Neurosurg 2022; 164:276-280. [PMID: 35618236 DOI: 10.1016/j.wneu.2022.05.071] [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: 04/30/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To conduct a retrospective analysis of the safety and efficacy of one session treatment with cranioplasty and STA-MCA bypass after decompressive craniectomy (DC)in hemorrhagic moyamoya disease. METHODS From March 2019 to August 2021, five patients with hemorrhagic MMD after DC were admitted in nan fang hospital. All patients received digital subtraction angiography (DSA) to exclude any spontaneous revascularization between the cortex and temporal muscle and the preservation of STA. Then one stage treatment with superficial temporal artery-middle cerebral artery (STA-MCA) bypass and cranioplasty were performed. If no suitable recipient artery was available, an encephalo-myo-synangiosis (EMS) procedure was used as a salvage plan. RESULTS Four patients underwent direct STA-MCA bypass, while one underwent EMS due to absence of a suitable recipient artery. All patients had no hemorrhage on postoperative CT, and no new infarcts were detected on MRI. There were no new recurrent symptoms at clinical follow-up 8 to 24 months after surgery. Three patients had improved Glasgow Outcome Scores (GOS), and two patients had stable GOS scores. Perfusion CT showed improvement in cerebral hemodynamics. Four DSA follow-up were performed, suggesting graft patency. CONCLUSION One session treatment with EC-IC bypass and cranioplasty are safe and effective in patients with MMD who have undergone previous decompressive craniectomy due to hemorrhagic attack.
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Affiliation(s)
- Gang Wang
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China; People's hospital of Huazhou
| | - Zhibin Wang
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China
| | - Yunyu Wen
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China
| | - Siyuan Chen
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China
| | - Mingzhou Li
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China
| | - Guozhong Zhang
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China
| | - Huiping Yu
- Quanzhou First Hospital, Fujian Medical University, China
| | - Shichao Zhang
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China
| | - Haiyan Xu
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China
| | - Songtao Qi
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China
| | - Wenfeng Feng
- Department of neurosurgery, Nanfang Hospital, Southern Medical University, China.
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17
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Spake CS, Goli R, Beqiri D, Crozier JW, Cielo DJ, Klinge PM, Svokos K, Woo AS. Evidence of linear bone flap resorption in patients undergoing autologous cranioplasty following decompressive craniectomy: A 3D Slicer segmented analysis of serial CT images. World Neurosurg 2022; 164:e799-e807. [PMID: 35597539 DOI: 10.1016/j.wneu.2022.05.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Autologous cranioplasty (CP) following decompressive craniectomy (DC) carries risk of bone flap resorption (BFR). The current literature offers limited information regarding the natural progression of BFR, and the rate at which it occurs. We aim to characterize the progression of BFR over time and elucidate risk factors for accelerated BFR. METHODS A retrospective analysis was conducted on patients who underwent DC and autologous CP. Serial computed tomography (CT) images were used to quantify degree of BFR over time. Risk factors included age, diabetes, smoking status, flap fragmentation, defect size, and DC-CP time interval. Chi-square analyses and Student's t-tests were performed to examine differences between patients who experienced BFR and those who did not. RESULTS Overall, 82% of patients demonstrated evidence of clinically relevant resorption on CT. On average, the bone flap decreased in volume by 36.7% within the first year, with a linear loss in volume after multiple years of follow-up. Individuals who developed greater BFR were significantly younger (43 ± 17 vs. 56 ± 12, p=0.022), had a lower incidence of diabetes (5.9% vs. 43%, p=0.037), and had more bone flap fragments (1.4 ± 0.67 vs. 1.00 ± 0, p <0.001) than those who did not. CONCLUSION Resorption following CP with cryopreserved bone appears to progress in a fairly linear and continuous fashion over time. Using serial CT images, we found a resorption rate of 82% at our institution. We identified several possible risk factors for resorption, including flap fragmentation, younger age, and absence of diabetes.
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Affiliation(s)
- Carole Sl Spake
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI.
| | - Rachna Goli
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Dardan Beqiri
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Joseph W Crozier
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Deus J Cielo
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Petra M Klinge
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Konstantina Svokos
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Albert S Woo
- Division of Plastic Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
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18
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Post R, Germans MR, Buis DR, Coert BA, Vandertop WP, Verbaan D. Interventions in Acute Intracranial Surgery: An Evidence-Based Perspective. World Neurosurg 2022; 161:432-440. [PMID: 35505564 DOI: 10.1016/j.wneu.2022.02.049] [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: 09/14/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 11/29/2022]
Abstract
From a pathophysiological point of view, early neurosurgical treatment seems essential to prevent secondary brain injury and has been stated as the "time-is-brain" concept. However, the question immediately rises: "Is there an optimal time window for acute intracranial neurosurgical interventions?" In neurosurgery, treatment modality has been studied far more extensively than timing to surgery ("time-to-surgery"). The majority of acute intracranial neurosurgical interventions are carried out for traumatic brain injury and hemorrhagic or ischemic stroke. Current guidelines for traumatic brain injury, spontaneous intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, and middle cerebral artery infarction are reviewed and lessons learned from the randomized controlled trials mentioned are discussed. In acute intracranial neurosurgical interventions, "delayed consent" procedures could play an important role for this field of research. Whether there is an optimal time window for acute intracranial neurosurgical interventions seems difficult to be answered with randomized controlled trials referred to in the current guidelines. Observational designs, such as comparative effectiveness research, and special statistical techniques, may provide a better understanding in the optimal "time-to-surgery."
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Affiliation(s)
- René Post
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| | - Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Centre, University Hospital Zurich, Zurich, Switzerland
| | - Dennis R Buis
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands
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Abstract
PURPOSE OF REVIEW To discuss recent advances in the critical care management of acute ischaemic stroke patients and highlight controversies and consensus. RECENT FINDINGS Intravenous thrombolysis and endovascular thrombectomy are standard of care reperfusion therapies that have revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. They can now be delivered in extended time windows and to those previously ineligible for intervention based on advanced neuroimaging criteria. Secondary systemic insults, such as hypo- and hypertension, hyperthermia or hyperglycaemia, which can extend the area of ischaemia must also be prevented or corrected to minimize infarct progression. Meticulous blood pressure management is of central importance, particularly in patients that have undergone reperfusion therapies. Neurological deterioration can occur because of infarct extension, haemorrhagic transformation or worsening cerebral oedema. Transcranial Doppler ultrasonography allows bedside, noninvasive evaluation of cerebral haemodynamics and is increasingly used in acute stroke triage, management and recovery prediction. The management of acute ischaemic stroke raises several ethical issues, and shared decision making is essential to ensure outcomes that are compatible with an individual patient's expectations. SUMMARY A bundle of medical, endovascular and surgical strategies implemented by a multidisciplinary team working to locally agreed protocols can improve long-term stroke outcomes.
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20
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Suarez-Meade P, Marenco-Hillembrand L, Sherman WJ. Neuro-oncologic Emergencies. Curr Oncol Rep 2022; 24:975-984. [PMID: 35353348 DOI: 10.1007/s11912-022-01259-3] [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: 02/18/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Patients with brain and spine tumors are at high risk of presenting cancer-related complications at disease presentation or during active treatment and are usually related to the type and location of the lesion. Here, we discuss presentation and management of the most common emergencies affecting patients with central nervous system neoplastic lesions. RECENT FINDINGS Tumor-related emergencies encompass complications in patients with central nervous system neoplasms, as well as neurologic complications in patients with systemic malignancies. Brain tumor patients are at high risk of developing multiple complications such as intracranial hypertension, brain herniation, intracranial bleeding, spinal cord compression, and others. Neuro-oncologic emergencies require immediate attention and multi-disciplinary care. These emergent situations usually need rapid decision-making and management on an inpatient basis.
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Affiliation(s)
| | | | - Wendy J Sherman
- Department of Neurology and Neurosurgery, Mayo Clinic, Jacksonville, FL, USA.
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21
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Robba C, van Dijk EJ, van der Jagt M. Acute ischaemic stroke and its challenges for the intensivist. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:258-268. [PMID: 35134852 DOI: 10.1093/ehjacc/zuac004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 06/14/2023]
Abstract
Acute ischaemic stroke (AIS) is responsible for almost 90% of all strokes and is one of the leading causes of death and disability. Acute ischaemic stroke is caused by a critical alteration in focal cerebral blood flow (ischaemia) from a variety of causes, resulting in infarction. The primary cerebral injury due to AIS occurs in the first hours, therefore early reperfusion importantly impacts on patient outcome ('Time is brain' concept). Secondary cerebral damage progressively evolves over the following hours and days due to cerebral oedema, haemorrhagic transformation, and cerebral inflammation. Systemic complications, such as pneumonia, sepsis, and deep venous thrombosis, could also affect outcome. The risk of a recurrent ischaemic stroke is in particular high in the first days, which necessitate particular attention. The role of intensive care unit physicians is therefore to avoid or reduce the risk of secondary damage, especially in the areas where the brain is functionally impaired and 'at risk' of further injury. Therapeutic strategies therefore consist of restoration of blood flow and a bundle of medical, endovascular, and surgical strategies, which-when applied in a timely and consistent manner-can prevent secondary deterioration due to cerebral and systemic complications and recurrent stroke and improve short- and long-term outcomes. A multidisciplinary collaboration between neurosurgeons, interventional radiologists, neurologists, and intensivists is necessary to elaborate the best strategy for the treatment of these patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche Integrate, University of Genova, Genova, Italy
| | - Ewoud J van Dijk
- Department of Neurology, Donders Institute for Brain Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
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22
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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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A Clinical Study on Individualized Surgical Scheme of Hydrocephalus Complicated With Skull Defect. J Craniofac Surg 2021; 32:2435-2440. [PMID: 34705388 DOI: 10.1097/scs.0000000000007571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE This study intends to discuss the individualized selection of surgical scheme of hydrocephalus complicated with skull defect. METHODS A total of 141 patients with hydrocephalus complicated with skull defect in our hospital from January 2012 to December 2018 were the main subjects of this study. Among these 141 patients, 78 patients underwent shunt and skull repair surgery in our hospital. In the present study, according to the classification of bone window tension, and combined with factors that affect the operation, different surgical schemes were selected, namely, repair surgery in the first phase and shunt surgery in the second phase, or simultaneous surgery, or shunt surgery in the first phase and repair surgery in the second phase. RESULTS The results of the present study show that an individualized surgical scheme can allow for the operation of hydrocephalus complicated with skull defect, without increasing the risk of complications, such as shunt infection, epidural hematoma, etc. CONCLUSIONS The surgical scheme for hydrocephalus complicated with skull defect differs in clinic.
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24
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Robba C, Iannuzzi F, Taccone FS. Tier-three therapies for refractory intracranial hypertension in adult head trauma. Minerva Anestesiol 2021; 87:1359-1366. [PMID: 34337922 DOI: 10.23736/s0375-9393.21.15827-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Refractory intracranial hypertension after traumatic brain injury (TBI) is defined as recurrent increase of intracranial pressure (ICP) above 20-22 mmHg for sustained period of time (10-15 min), despite conventional therapies, such as osmotic therapy, cerebral spinal fluid drainage and mild hyperventilation. As such, more aggressive treatments should be taken into consideration. In particular, therapeutic hypothermia, barbiturates administration and decompressive craniectomy are considered as tier-three or "salvage" interventions, as they have shown to be able to control refractory hypertension, but are also associated with an increased risk of significant side effects. The aim of this review is therefore to describe the evidence supporting the use of these tier-three therapies in the management of refractory intracranial hypertension in TBI patients.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy - .,San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy -
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio S Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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25
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Huang W, Zhou B, Li Y, Shao Y, Peng B, Jiang X, Xiang T. Effectiveness and Safety of Pressure Dressings on Reducing Subdural Effusion After Decompressive Craniectomy. Neuropsychiatr Dis Treat 2021; 17:3119-3125. [PMID: 34703231 PMCID: PMC8524178 DOI: 10.2147/ndt.s332653] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/08/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Decompressive craniectomy as a treatment is often used in the rescue treatment of critically ill patients in neurosurgery; however, there are many complications after this operation. Subdural effusion is a common complication after decompressive craniectomy. Once it occurs, it can cause further problems for the patient. Therefore, the purpose of this study was to explore the safety and effectiveness of pressure dressings for subdural effusion after decompressive craniectomy. METHODS Patients who underwent decompressive craniectomy in our hospital from January 2016 to January 2021 were included in this study, and all patients were followed up for 6 months or more. After the operation, the patients were divided into two groups according to whether they received a pressure dressing or a traditional dressing. Subdural effusion, cerebrospinal fluid leakage, hydrocephalus and other complications were compared between the two groups, and the differences in hospital duration, cost and prognosis between the two groups were analyzed. RESULTS A total of 123 patients were included in this study. Among them, 62 patients chose pressure dressings, and 61 patients chose traditional dressings. The incidence of subdural effusion in the pressure dressing group was significantly lower than that in the traditional dressing group (P<0.05). There was no difference between the two groups in cerebrospinal fluid leakage and hydrocephalus (P > 0.05). In addition, the length of hospital stay and the total cost in the pressure dressing group were significantly lower (P<0.05). CONCLUSION Pressure dressing can effectively reduce the occurrence of subdural effusion after decompressive craniectomy, and it does not increase the occurrence of other cerebrospinal fluid-related complications.
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Affiliation(s)
- Wanyong Huang
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Bo Zhou
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Yingwei Li
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Yuansheng Shao
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Bo Peng
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Xianchun Jiang
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
| | - Tao Xiang
- Department of Neurosurgery, People's Hospital of Guanghan City, Guanghan City, Sichuan Province, People's Republic of China
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26
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Quiñones-Ossa GA, Shrivastava A, Perdomo WAF, Moscote-Salazar LR, Agrawal A. Immunomodulatory Effect of Hypertonic Saline Solution in Traumatic Brain-Injured Patients and Intracranial Hypertension. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
AbstractTraumatic brain injury (TBI) is often associated with an increase in the intracranial pressure (ICP). This increase in ICP can cross the physiological range and lead to a reduction in cerebral perfusion pressure (CPP) and the resultant cerebral blood flow (CBF). It is this reduction in the CBF that leads to the secondary damage to the neural parenchyma along with the physical axonal and neuronal damage caused by the mass effect. In certain cases, a surgical intervention may be required to either remove the mass lesion (hematoma of contusion evacuation) or provide more space to the insulted brain to expand (decompressive craniectomy). Whether or not a surgical intervention is performed, all these patients require some form of pharmaceutical antiedema agents to bring down the raised ICP. These agents have been broadly classified as colloids (e.g., mannitol, glycerol, urea) and crystalloids (e.g., hypertonic saline), and have been used since decades. Even though mannitol has been the workhorse for ICP reduction owing to its unique properties, crystalloids have been found to be the preferred agents, especially when long-term use is warranted. The safest and most widely used agent is hypertonic saline in various concentrations. Whatever be the concentration, hypertonic saline has created special interest among physicians owing to its additional property of immunomodulation and neuroprotection. In this review, we summarize and understand the various mechanism by which hypertonic saline exerts its immunomodulatory effects that helps in neuroprotection after TBI.
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Affiliation(s)
| | - Adesh Shrivastava
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | | | - Luis R. Moscote-Salazar
- Department of Neurocritical Care, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Chakravarthi SS, Lyons L, Orozco AR, Verhey L, Mazaris P, Zacharia J, Singer JA. Combined Decompressive Hemicraniectomy and Port-Based Minimally Invasive Parafascicular Surgery for the Treatment of Subcortical Intracerebral Hemorrhage: Case Series, Technical Note, and Review of Literature. World Neurosurg 2020; 146:e1226-e1235. [PMID: 33271377 DOI: 10.1016/j.wneu.2020.11.130] [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: 08/29/2020] [Revised: 11/23/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a neurosurgical emergency. Combined decompressive hemicraniectomy (DHC) and minimally invasive parafascicular surgery (MIPS) may provide a practical method of managing subcortical ICH. OBJECTIVE 1) To present a case series of combined DHC-MIPS for the treatment of subcortical-based ICH; 2) to describe technical nuances of DHC-MIPS; and 3) to provide a literature overview of MIPS for ICH. METHODS The following inclusion criteria were used: 1) Glasgow Coma Scale (GCS) score <3-4; 2) admission within 6 hours of onset; 3) increased intracranial pressure caused by hemorrhage; 4) patient unresponsive to medical management; 5) hemorrhage >30 cm3; 6) subcortical location; and 7) midline shift (mm). Before DHC, sulcal cannulation used the following coordinates: intersection of tragus-frontal bone and midpoint of midpupillary line and midline; coronal suture: 3-4 cm posterior to this point). RESULTS Three patients were selected: a 62-year old woman, a 45-year old woman, and a 36-year-old man. GCS and ICH scores on admission were 7 and 3, 3 and 4, and 3 and 4, respectively. ICH was located in left basal ganglia in patients 1 and 3 and right basal ganglia in patient 2, all with intraventricular extension. ICH volume was 81.7, 68.2, and 42.3 cm3, respectively. The postoperative GCS score was 11, 10, and 6, respectively. There were no intraoperative complications or mortalities. Evacuation was within 15 minutes in all patients. The modified Rankin Scale score was 3, 4, and 5, respectively, with semi-independence in case 1. CONCLUSIONS Combined DHC-MIPS, with the use of craniometric points, can provide a unique and simple surgical option for the management of subcortical ICH.
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Affiliation(s)
- Srikant S Chakravarthi
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Leah Lyons
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Andres Restrepo Orozco
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Leonard Verhey
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Paul Mazaris
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Joseph Zacharia
- Department of Neurocritical Care, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Justin A Singer
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA.
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Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. Neurologia 2020; 38:S0213-4853(20)30274-7. [PMID: 33069447 DOI: 10.1016/j.nrl.2020.08.007] [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: 02/17/2020] [Revised: 07/20/2020] [Accepted: 08/04/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Increased intracranial pressure has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury. Traditionally, intracranial pressure-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe traumatic brain injury in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.
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Affiliation(s)
- C E Escamilla-Ocañas
- Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, EE. UU..
| | - N Albores-Ibarra
- División de Ciencias de la Salud, Universidad de Monterrey, San Pedro Garza García, Nuevo León, México
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29
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Rosinski CL, Behbahani M, Geever B, Chaker AN, Patel S, Chiu R, Zakrzewski J, Rosenberg D, Parola R, Shah K, Mehta AI. Concurrent Versus Staged Procedures for Ventriculoperitoneal Shunt and Cranioplasty: A 10-Year Retrospective Comparative Analysis of Surgical Outcomes. World Neurosurg 2020; 143:e648-e655. [PMID: 32798784 DOI: 10.1016/j.wneu.2020.08.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Many patients undergoing decompressive craniectomy will develop persistent hydrocephalus before cranioplasty. Therefore, surgeons must decide whether to perform ventriculoperitoneal shunt (VPS) placement and cranioplasty simultaneously or in staged procedures. With limited, conflicting data reported, this decision has often been made by personal preference. The objective of the present study was to compare the surgical outcomes between patients undergoing concurrent or staged VPS placement and cranioplasty. METHODS We performed a 10-year retrospective comparative analysis of patients who had undergone either simultaneous or staged VPS placement and cranioplasty at a tertiary academic medical center. RESULTS Of the 40 patients, 18 had undergone concurrent procedures and 22 had undergone VPS placement before a separate cranioplasty procedure. The concurrent group was significantly older, had more often had the VPS placed in the external ventricular drain site, and had had more patients taking aspirin at surgery. The rates of infection, resorption, and reoperation did not differ significantly, although reoperation showed a trend toward occurring less frequently in the concurrent group. Hospital-acquired infection occurred significantly less frequently in the concurrent patients. The rate of VPS-associated outcomes did not differ significantly between the 2 groups. CONCLUSIONS Because of the trend toward a reduced reoperation rate, the significantly reduced rate of hospital-acquired infection, and the reduction in the number of surgeries, we recommend that patients awaiting cranioplasty in the setting of persistent hydrocephalus undergo concurrent VPS placement and cranioplasty rather than staged procedures.
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Affiliation(s)
- Clayton L Rosinski
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mandana Behbahani
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Brett Geever
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Anisse N Chaker
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Saavan Patel
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ryan Chiu
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jack Zakrzewski
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - David Rosenberg
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Rown Parola
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Koral Shah
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ankit I Mehta
- Department of Neurosurgery, The University of Illinois at Chicago, Chicago, Illinois, USA.
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30
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Smith M, Servadei F, Hutchinson PJ. What is new in decompressive craniectomy in neurological emergencies: the good, the bad and the ugly. Intensive Care Med 2020; 46:1023-1026. [PMID: 31996957 DOI: 10.1007/s00134-020-05933-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/11/2020] [Indexed: 10/25/2022]
Affiliation(s)
- M Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK. .,Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - F Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milano, Italy
| | - P J Hutchinson
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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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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Smith M, Reddy U, Robba C, Sharma D, Citerio G. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med 2019; 45:1177-1189. [PMID: 31346678 DOI: 10.1007/s00134-019-05705-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/17/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To provide an update about the rapidly developing changes in the critical care management of acute ischaemic stroke patients. METHODS A narrative review was conducted in five general areas of acute ischaemic stroke management: reperfusion strategies, anesthesia for endovascular thrombectomy, intensive care unit management, intracranial complications, and ethical considerations. RESULTS The introduction of effective reperfusion strategies, including IV thrombolysis and endovascular thrombectomy, has revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. Acute therapeutic efforts are targeted to restoring blood flow to the ischaemic penumbra before irreversible tissue injury has occurred. To optimize patient outcomes, secondary insults, such as hypotension, hyperthermia, or hyperglycaemia, that can extend the penumbral area must also be prevented or corrected. The ICU management of acute ischaemic stroke patients, therefore, focuses on the optimization of systemic physiological homeostasis, management of intracranial complications, and neurological and haemodynamic monitoring after reperfusion therapies. Meticulous blood pressure management is of central importance in improving outcomes, particularly in patients that have undergone reperfusion therapies. CONCLUSIONS While consensus guidelines are available to guide clinical decision making after acute ischaemic stroke, there is limited high-quality evidence for many of the recommended interventions. However, a bundle of medical, endovascular, and surgical strategies, when applied in a timely and consistent manner, can improve long-term stroke outcomes.
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Affiliation(s)
- M Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK. .,Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - U Reddy
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK
| | - C Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - D Sharma
- Division of Neuroanesthesiology and Perioperative Neurosciences, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| | - G Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, MB, Italy
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Contemporary Management of Increased Intraoperative Intracranial Pressure: Evidence-Based Anesthetic and Surgical Review. World Neurosurg 2019; 129:120-129. [PMID: 31158533 DOI: 10.1016/j.wneu.2019.05.224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 12/29/2022]
Abstract
Increased intracranial pressure (ICP) is frequently encountered in the neurosurgical setting. A multitude of tactics exists to reduce ICP, ranging from patient position and medications to cerebrospinal fluid diversion and surgical decompression. A vast amount of literature has been published regarding ICP management in the critical care setting, but studies specifically tailored toward the management of intraoperative acute increases in ICP or brain bulk are lacking. Compartmentalizing the intracranial space into blood, brain tissue, and cerebrospinal fluid and understanding the numerous techniques available to affect these individual compartments can guide the surgical team to quickly identify increased brain bulk and respond appropriately. Rapidly instituting measures for brain relaxation in the operating room is essential in optimizing patient outcomes. Knowledge of the efficacy, rapidity, feasibility, and risks of the various available interventions can aid the team to properly tailor their approach to each individual patient. In this article, we present the first evidence-based review of intraoperative management of ICP and brain bulk.
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Rossini Z, Nicolosi F, Kolias AG, Hutchinson PJ, De Sanctis P, Servadei F. The History of Decompressive Craniectomy in Traumatic Brain Injury. Front Neurol 2019; 10:458. [PMID: 31133965 PMCID: PMC6517544 DOI: 10.3389/fneur.2019.00458] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/16/2019] [Indexed: 01/01/2023] Open
Abstract
Decompressive craniectomy consists of removal of piece of bone of the skull in order to reduce intracranial pressure. It is an age-old procedure, taking ancient roots from the Egyptians and Romans, passing through the experience of Berengario da Carpi, until Theodore Kocher, who was the first to systematically describe this procedure in traumatic brain injury (TBI). In the last century, many neurosurgeons have reported their experience, using different techniques of decompressive craniectomy following head trauma, with conflicting results. It is thanks to the successes and failures reported by these authors that we are now able to better understand the pathophysiology of brain swelling in head trauma and the role of decompressive craniectomy in mitigating intracranial hypertension and its impact on clinical outcome. Following a historical description, we will describe the steps that led to the conception of the recent randomized clinical trials, which have taught us that decompressive craniectomy is still a last-tier measure, and decisions to recommend it should been made not only according to clinical indications but also after consideration of patients' preferences and quality of life expectations.
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Affiliation(s)
- Zefferino Rossini
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Federico Nicolosi
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | | | - Franco Servadei
- Research Hospital, Humanitas University, Pieve Emanuele, Italy
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35
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Clavijo A, Khan AA, Mendoza J, Montenegro JH, Johnson ED, Adeleye AO, Rubiano AM. The Role of Decompressive Craniectomy in Limited Resource Environments. Front Neurol 2019; 10:112. [PMID: 30863354 PMCID: PMC6399379 DOI: 10.3389/fneur.2019.00112] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/28/2019] [Indexed: 12/12/2022] Open
Abstract
Decompressive craniectomy (DC) is a neurosurgical procedure useful to prevent and manage the impact of high intracranial pressure (ICP) that leads to brain herniation and brain's tissue ischemia. In well-resourced environment this procedure has been proposed as a last tier therapy when ICP is not controlled by medical therapies in the management of different neurosurgical emergencies like traumatic brain injury (TBI), stroke, infectious diseases, hydrocephalus, tumors, etc. The purpose of this narrative review is to discuss the role of DC in areas of low neurosurgical and neurocritical care resources. We performed a literature review with a specific search strategy in web repositories and some local and regional journals from Low and Middle-Income Countries (LMICs). The most common publications include case reports, case series and observational studies describing the benefits of the procedure on different pathologies but with several types of biases due to the absence of robust studies or clinical registries analysis in these kinds of environments.
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Affiliation(s)
- Angélica Clavijo
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Ahsan A Khan
- MEDITECH Foundation, Clinical Research, Cali, Colombia.,Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Juliana Mendoza
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Jorge H Montenegro
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Erica D Johnson
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Amos O Adeleye
- Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom.,College of Medicine, University of Ibadan, and University College Hospital (UCH), Ibadan, Nigeria
| | - Andrés M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia.,MEDITECH Foundation, Clinical Research, Cali, Colombia.,Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI): Translating limited science evidence into robust practical recommendations. Anaesth Crit Care Pain Med 2018; 37:111-112. [PMID: 29555178 DOI: 10.1016/j.accpm.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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37
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Kolias AG, Viaroli E, Rubiano AM, Adams H, Khan T, Gupta D, Adeleye A, Iaccarino C, Servadei F, Devi BI, Hutchinson PJ. The current status of decompressive craniectomy in traumatic brain injury. CURRENT TRAUMA REPORTS 2018; 4:326-332. [PMID: 30473990 PMCID: PMC6244550 DOI: 10.1007/s40719-018-0147-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE This review describes the evidence base that has helped define the role of decompressive craniectomy (DC) in the management of patients with traumatic brain injury (TBI). RECENT FINDINGS The publication of two randomized trials (DECRA and RESCUEicp) has strengthened the evidence base. The DECRA trial showed that neuroprotective bifrontal DC for moderate intracranial hypertension is not helpful, whereas the RESCUEicp trial found that last-tier DC for severe and refractory intracranial hypertension can significantly reduce the mortality rate but is associated with a higher rate of disability. These findings have reopened the debate about 1) the indications for DC in various TBI subtypes, 2) alternative techniques (e.g. hinge craniotomy), 3) optimal time and material for cranial reconstruction, and 4) the role of shared decision-making in TBI care. Additionally, the role of primary DC when evacuating an acute subdural hematoma is currently undergoing evaluation in the context of the RESCUE-ASDH randomized trial. SUMMARY This review provides an overview of the current evidence base, discusses its limitations and presents a global perspective on the role of DC, as there is growing recognition that attention should also focus on low- and middle-income countries due to their much greater TBI burden.
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Affiliation(s)
- Angelos G. Kolias
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke’s Hospital & University of Cambridge, Cambridge, CB2 0QQ UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Edoardo Viaroli
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Andres M. Rubiano
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Neuroscience Institute, INUB-MEDITECH Research Group, El Bosque University, Bogotá, Colombia
| | - Hadie Adams
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke’s Hospital & University of Cambridge, Cambridge, CB2 0QQ UK
| | - Tariq Khan
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Deepak Gupta
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amos Adeleye
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Surgery, Division of Neurological Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Corrado Iaccarino
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
| | - Bhagavatula Indira Devi
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Peter J. Hutchinson
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke’s Hospital & University of Cambridge, Cambridge, CB2 0QQ UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
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Current Perspectives in the Surgical Treatment of Severe Traumatic Brain Injury. World Neurosurg 2018; 116:322-328. [DOI: 10.1016/j.wneu.2018.05.176] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/22/2018] [Accepted: 05/24/2018] [Indexed: 12/14/2022]
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