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Kapapa T, Jesuthasan S, Schiller F, Schiller F, Oehmichen M, Woischneck D, Mayer B, Pala A. Outcome after Intracerebral Haemorrhage and Decompressive Craniectomy in Older Adults. Neurol Int 2024; 16:590-604. [PMID: 38804483 PMCID: PMC11130851 DOI: 10.3390/neurolint16030044] [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: 03/24/2024] [Revised: 05/11/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE There is a relationship between the incidence of spontaneous intracerebral haemorrhage (ICH) and age. The incidence increases with age. This study aims to facilitate the decision-making process in the treatment of ICH. It therefore investigated the outcome after ICH and decompressive craniectomy (DC) in older adults (>65 years of age). METHODS Retrospective, multicentre, descriptive observational study including only consecutive patients who received DC as the consequence of ICH. Additive evacuation of ICH was performed after the individual decision of the neurosurgeon. Besides demographic data, clinical outcomes both at discharge and 12 months after surgery were evaluated according to the Glasgow Outcome Scale (GOS). Patients were divided into age groups of ≤65 and >65 years and cohorts with favourable outcome (GOS IV-V) and unfavourable outcome (GOS I to III). RESULTS 56 patients were treated. Mean age was 53.3 (SD: 16.13) years. There were 41 (73.2%) patients aged ≤65 years and 15 (26.8%) patients aged >65 years. During hospital stay, 10 (24.4%) patients in the group of younger (≤65 years) and 5 (33.3%) in the group of older patients (>65 years) died. Mean time between ictus and surgery was 44.4 (SD: 70.79) hours for younger and 27.9 (SD: 41.71) hours for older patients. A disturbance of the pupillary function on admission occurred in 21 (51.2%) younger and 2 (13.3%) older patients (p = 0.014). Mean arterial pressure was 99.9 (SD: 17.00) mmHg for younger and 112.9 (21.80) mmHg in older patients. After 12 months, there was no significant difference in outcome between younger patients (≤65 years) and older patients (>65 years) after ICH and DC (p = 0.243). Nevertheless, in the group of younger patients (≤65 years), 9% had a very good and 15% had a good outcome. There was no good recovery in the group of older patients (>65 years). CONCLUSION Patients >65 years of age treated with microsurgical haematoma evacuation and DC after ICH are likely to have a poor outcome. Furthermore, in the long term, only a few older adults have a good functional outcome with independence in daily life activities.
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Affiliation(s)
- Thomas Kapapa
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Stefanie Jesuthasan
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Frederike Schiller
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Franziska Schiller
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Marcel Oehmichen
- Department of Neurosurgery, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Dieter Woischneck
- Department of Neurosurgery, Hospital Landshut, Robert-Koch-Strasse 1, 84034 Landshut, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Schwabstrasse 13, 89075 Ulm, Germany
| | - Andrej Pala
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Fuchs A, Bartolf-Kopp M, Böhm H, Straub A, Kübler AC, Linz C, Gbureck U. Composite grafts made of polycaprolactone fiber mats and oil-based calcium phosphate cement pastes for the reconstruction of cranial and maxillofacial defects. Clin Oral Investig 2023; 27:3199-3209. [PMID: 36864278 PMCID: PMC10264493 DOI: 10.1007/s00784-023-04932-4] [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: 09/08/2022] [Accepted: 02/23/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVES Synthetic bone substitutes which can be adapted preoperatively and patient specific may be helpful in various bony defects in the field of oral- and maxillofacial surgery. For this purpose, composite grafts made of self-setting and oil-based calcium phosphate cement (CPC) pastes, which were reinforced with 3D-printed polycaprolactone (PCL) fiber mats were manufactured. MATERIALS AND METHODS Bone defect models were acquired using patient data from real defect situations of patients from our clinic. Using a mirror imaging technique, templates of the defect situation were fabricated via a commercially available 3D-printing system. The composite grafts were assembled layer by layer, aligned on top of these templates and fitted into the defect situation. Besides, PCL-reinforced CPC samples were evaluated regarding their structural and mechanical properties via X-ray diffraction (XRD), infrared (IR) spectroscopy, scanning electron microscopy (SEM), and 3-point-bending testing. RESULTS The process sequence including data acquisition, template fabrication, and manufacturing of patient specific implants proved to be accurate and uncomplicated. The individual implants consisting mainly of hydroxyapatite and tetracalcium phosphate displayed good processability and a high precision of fit. The mechanical properties of the CPC cements in terms of maximum force and stress load to material fatigue were not negatively affected by the PCL fiber reinforcement, whereas clinical handling properties increased remarkably. CONCLUSION PCL fiber reinforcement of CPC cements enables the production of very freely modelable three-dimensional implants with adequate chemical and mechanical properties for bone replacement applications. CLINICAL RELEVANCE The complex bone morphology in the region of the facial skull often poses a great challenge for a sufficient reconstruction of bony defects. A full-fledged bone replacement here often requires the replication of filigree three-dimensional structures partly without support from the surrounding tissue. With regard to this problem, the combination of smooth 3D-printed fiber mats and oil-based CPC pastes represents a promising method for fabricating patient specific degradable implants for the treatment of various craniofacial bone defects.
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Affiliation(s)
- Andreas Fuchs
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany.
| | - Michael Bartolf-Kopp
- Department for Functional Materials in Medicine and Dentistry, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
| | - Hartmut Böhm
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
| | - Anton Straub
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
| | - Alexander C Kübler
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
| | - Christian Linz
- Department of Oral and Maxillofacial Plastic Surgery, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
- Department of Oral and Maxillofacial Plastic Surgery, Faculty of Medicine and University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Uwe Gbureck
- Department for Functional Materials in Medicine and Dentistry, University Hospital Würzburg, Pleicherwall 2, 97070, Würzburg, Germany
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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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Cardali SM, Caffo M, Caruso G, Scalia G, Gorgoglione N, Conti A, Vinci SL, Barresi V, Granata F, Ricciardo G, Garufi G, Raffa G, Germanò A. Cisternostomy for malignant middle cerebral artery infarction: proposed pathophysiological mechanisms and preliminary results. Stroke Vasc Neurol 2022; 7:476-481. [PMID: 35672081 PMCID: PMC9811554 DOI: 10.1136/svn-2021-000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/16/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The ischaemic stroke of the territory of the middle cerebral artery represents an event burdened by high mortality and severe morbidity. The proposed medical treatments do not always prove effective. Decompressive craniectomy allows the ischaemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. In this study, we propose a novel treatment for these patients characterised by surgical fenestration of the cisterns of the skull base. METHODS We have treated 16 patients affected by malignant middle cerebral artery ischaemia and treated with cisternostomy between August 2018 and December 2019. The clinical history, neurological examination findings and neuroradiological studies (brain CT, CT angiography, MRI) were performed to diagnose stroke. Clinical examination was recorded on admission and preoperatively using the Glasgow Coma Scale and the National Institutes of Health Stroke Scale. RESULTS The study included 16 patients, 10 males and 6 females. The mean age at surgery was 60.1 years (range 19-73). Surgical procedure was performed in all patients. The patients underwent immediate postoperative CT scan and were in the early hours evaluated in sedation window. In total, we recorded two deaths (12.5%). A functional outcome between mRS 0-3, defined as favourable, was observed in 9 (64.2%) patients 9 months after discharge. A functional outcome between mRS 4-6, defined as poor, was observed in 5 (35.7%) patients 9 months after discharge. CONCLUSIONS The obtained clinical results appear, however, substantially overlapping to decompressive craniectomy. Cisternostomy results in a favourable functional outcome after 9 months. This proposed technique permits that the patient no longer should be undergone cranioplasty thus avoiding the possible complications related to this procedure. The results are certainly interesting but higher case numbers are needed to reach definitive conclusions.
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Affiliation(s)
- Salvatore Massimiliano Cardali
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Maria Caffo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Gerardo Caruso
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Gianluca Scalia
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Nicola Gorgoglione
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Alfredo Conti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Sergio Lucio Vinci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neuroradiology, University of Messina, Messina, Italy
| | - Valeria Barresi
- Department of Diagnostics and Public Health, Section of Anatomic Pathology, University of Verona, Verona, Italy
| | - Francesca Granata
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Unit of Neuroradiology, University of Messina, Messina, Italy
| | - Giuseppe Ricciardo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Giada Garufi
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Giovanni Raffa
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
| | - Antonino Germanò
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Neurosurgical Clinic, University of Messina, Messina, Italy
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Zakharchenko S, Hansen A, Ibikunle A, Devasagayaraj R, Charles P. Intracranial hemorrhage detected through a craniotomy site with point of care ultrasound. J Am Coll Emerg Physicians Open 2021; 2:e12419. [PMID: 34179872 PMCID: PMC8212560 DOI: 10.1002/emp2.12419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 11/10/2022] Open
Abstract
A 60-year-old male presented to the emergency department with acute change in mental status while recovering from a recent hemicraniectomy. During evaluation by the emergency physician, a point-of-care ultrasound (POCUS) was performed using the patient's existing craniectomy site as a sonographic window. Multiple areas of intracranial hemorrhage were visualized on POCUS and head computed tomography scan ultimately requiring urgent neurosurgical intervention. Our case report demonstrates an innovative application of POCUS in the emergency department- setting that has potential to expedite diagnosis and management of life-threatening neurosurgical etiologies, such as hemorrhage and midline shift, in a unique patient population.
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Affiliation(s)
- Svetlana Zakharchenko
- Hackensack University Medical CenterHackensack Meridian HealthHackensackNew JerseyUSA
| | | | - Aminat Ibikunle
- Hackensack University Medical CenterHackensack Meridian HealthHackensackNew JerseyUSA
| | - Richard Devasagayaraj
- Hackensack University Medical CenterHackensack Meridian HealthHackensackNew JerseyUSA
| | - Patrick Charles
- Hackensack University Medical CenterHackensack Meridian HealthHackensackNew JerseyUSA
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Specificities of acute phase stroke management in the elderly. Rev Neurol (Paris) 2020; 176:684-691. [PMID: 32980154 DOI: 10.1016/j.neurol.2020.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 11/21/2022]
Abstract
Health professionals are currently facing the challenge of managing an increasing number of old patients presenting with acute stroke, due to rapid aging of the population. Compared to their younger counterparts, elderly patients differ in many ways in the setting of acute stroke. Apart from a striking high stroke incidence, which increases exponentially as age increases, cardioembolism also becomes, as patients age, the main cause of ischemic stroke. Delirium, which can challenge the diagnosis, is frequent at the acute phase of stroke, and may be related to an underlying dementia, which is almost exclusively observed in the elderly during stroke. At all levels, management of elderly stroke patients is suboptimal, especially when they are cognitively impaired, with insufficiencies including admission to stroke units, applying standards of care and investigation, reperfusion therapy for ischemic stroke, and finally transfer to rehabilitation centers. A paradigm shift must take place to limit age-related discrimination for acute-phase management of stroke.
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Paldor I, Peso D, Sviri GE. Decompressive craniectomy in elderly patients with traumatic brain injury. J Clin Neurosci 2020; 78:269-272. [PMID: 32334961 DOI: 10.1016/j.jocn.2020.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/20/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Iddo Paldor
- Rambam (Maimonides) Health Care Campus, Technion - Israel Institute of Technology, Haifa, Israel
| | - Dana Peso
- Rambam (Maimonides) Health Care Campus, Technion - Israel Institute of Technology, Haifa, Israel
| | - Gill E Sviri
- Rambam (Maimonides) Health Care Campus, Technion - Israel Institute of Technology, Haifa, Israel
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