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Sarikaya-Seiwert S, Shabo E, Schievelkamp AH, Born M, Wispel C, Haberl H. Decompressive craniotomy in split-technique (DCST) for TBI in infants: introducing a new surgical technique to prevent long-term complications. Childs Nerv Syst 2024; 40:2761-2768. [PMID: 38789688 PMCID: PMC11322217 DOI: 10.1007/s00381-024-06445-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Decompressive craniectomy (DC) is rarely required in infants. These youngest patients are vulnerable to blood loss, and cranial reconstruction can be challenging due to skull growth and bone flap resorption. On the other hand, infants have thin and flexible bone and osteogenic potential. MATERIAL AND METHODS: We propose a new technique called DCST, which makes use of these unique aspects by achieving decompression using the circumstance of the thin and flexible bone. We describe the surgical technique and the follow-up course over a period of 13 months. RESULTS AND CONCLUSION In our study, DCST achieved adequate decompression and no further repeated surgeries in accordance with decompressive craniectomy were needed afterwards.
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Affiliation(s)
- Sevgi Sarikaya-Seiwert
- Section of Pediatric Neurosurgery, Department of Neurosurgery, Medical Faculty, Rheinische Friedrich Wilhelms University, Venusberg Campus 1, Bonn, D-53127, Bonn, Germany.
| | - Ehab Shabo
- Section of Pediatric Neurosurgery, Department of Neurosurgery, Medical Faculty, Rheinische Friedrich Wilhelms University, Venusberg Campus 1, Bonn, D-53127, Bonn, Germany.
| | - Arndt-Hendrik Schievelkamp
- Department of Neuroradiology, University Hospital Bonn, 53127, Bonn, Germany
- Department of Neuroradiology, University Hospital Koeln, Koeln, Germany
| | - Mark Born
- Section of Pediatric Radiology, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Christian Wispel
- Section of Pediatric Neurosurgery, Department of Neurosurgery, Medical Faculty, Rheinische Friedrich Wilhelms University, Venusberg Campus 1, Bonn, D-53127, Bonn, Germany
| | - Hannes Haberl
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Munich, Germany
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Solomou G, Sunny J, Mohan M, Hossain I, Kolias AG, Hutchinson PJ. Decompressive craniectomy in trauma: What you need to know. J Trauma Acute Care Surg 2024:01586154-990000000-00780. [PMID: 39137371 DOI: 10.1097/ta.0000000000004357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
ABSTRACT Decompressive craniectomy (DC) is a surgical procedure in which a large section of the skull is removed, and the underlying dura mater is opened widely. After evacuating a traumatic acute subdural hematoma, a primary DC is typically performed if the brain is bulging or if brain swelling is expected over the next several days. However, a recent randomized trial found similar 12-month outcomes when primary DC was compared with craniotomy for acute subdural hematoma. Secondary removal of the bone flap was performed in 9% of the craniotomy group, but more wound complications occurred in the craniectomy group. Two further multicenter trials found that, whereas early neuroprotective bifrontal DC for mild to moderate intracranial hypertension is not superior to medical management, DC as a last-tier therapy for refractory intracranial hypertension leads to reduced mortality. Patients undergoing secondary last-tier DC are more likely to improve over time than those in the standard medical management group. The overall conclusion from the most up-to-date evidence is that secondary DC has a role in the management of intracranial hypertension following traumatic brain injury but is not a panacea. Therefore, the decision to offer this operation should be made on a case-by-case basis. Following DC, cranioplasty is warranted but not always feasible, especially in low- and middle-income countries. Consequently, a decompressive craniotomy, where the bone flap is allowed to "hinge" or "float," is sometimes used. Decompressive craniotomy is also an option in a subgroup of traumatic brain injury patients undergoing primary surgical evacuation when the brain is neither bulging nor relaxed. However, a high-quality randomized controlled trial is needed to delineate the specific indications and the type of decompressive craniotomy in appropriate patients.
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Affiliation(s)
- Georgios Solomou
- From the Division of Neurosurgery, Department of Clinical Neurosciences (G.S., J.S., M.M., I.H., A.G.K. P.J.H.), Addenbrooke's Hospital, University of Cambridge, Cambridge; National Hospital for Neurology and Neurosurgery (J.S.), London, United Kingdom; and Neurocenter (I.H.), Department of Neurosurgery, Turku University Hospital, Turku, Finland
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3
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Singh C, Gharde P, Iratwar S, Verma P, Triwedi B. Decompressive Craniectomy: From Ancient Practices to Modern Neurosurgery. Cureus 2024; 16:e64923. [PMID: 39156316 PMCID: PMC11330637 DOI: 10.7759/cureus.64923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/19/2024] [Indexed: 08/20/2024] Open
Abstract
Decompressive craniectomy (DC) is a neurosurgical strategy that expels a parcel of the cranium to relieve pressure on a swollen or herniating brain. This review article explores the history of DC, from its ancient roots in trepanning to its contemporary applications. It then examines the mechanisms by which DC reduces intracranial pressure (ICP) and improves cerebral blood flow. The article highlights the efficacy of DC in treating patients with severe traumatic brain injury (TBI), stroke, and other conditions that cause increased ICP. However, it also acknowledges the potential complications of DC, such as infection and bleeding. The ethical considerations surrounding DC are explored in detail, particularly the challenging decision-making process for patients who are unable to give consent. A specific focus is given to the use of DC in pediatric patients, where the developing brain is especially vulnerable to pressure changes.
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Affiliation(s)
- Chahat Singh
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Gharde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sandeep Iratwar
- Neurosurgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Prince Verma
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Bhushan Triwedi
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Ritter K, Somnuke P, Hu L, Griemert EV, Schäfer MKE. Current state of neuroprotective therapy using antibiotics in human traumatic brain injury and animal models. BMC Neurosci 2024; 25:10. [PMID: 38424488 PMCID: PMC10905838 DOI: 10.1186/s12868-024-00851-6] [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: 09/25/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
TBI is a leading cause of death and disability in young people and older adults worldwide. There is no gold standard treatment for TBI besides surgical interventions and symptomatic relief. Post-injury infections, such as lower respiratory tract and surgical site infections or meningitis are frequent complications following TBI. Whether the use of preventive and/or symptomatic antibiotic therapy improves patient mortality and outcome is an ongoing matter of debate. In contrast, results from animal models of TBI suggest translational perspectives and support the hypothesis that antibiotics, independent of their anti-microbial activity, alleviate secondary injury and improve neurological outcomes. These beneficial effects were largely attributed to the inhibition of neuroinflammation and neuronal cell death. In this review, we briefly outline current treatment options, including antibiotic therapy, for patients with TBI. We then summarize the therapeutic effects of the most commonly tested antibiotics in TBI animal models, highlight studies identifying molecular targets of antibiotics, and discuss similarities and differences in their mechanistic modes of action.
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Affiliation(s)
- Katharina Ritter
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
| | - Pawit Somnuke
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Lingjiao Hu
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
- Department of Gastroenterology, Nanxishan Hospital of Guangxi Zhuang Autonomous Region, Guilin, China
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
| | - Michael K E Schäfer
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany.
- Focus Program Translational Neurosciences (FTN, Johannes Gutenberg-University Mainz, Mainz, Germany.
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg- University Mainz, Mainz, Germany.
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Habibi MA, Kobets AJ, Boskabadi AR, Mousavi Nasab M, Sobhanian P, Saber Hamishegi F, Naseri Alavi SA. A comprehensive systematic review and meta-analysis study in comparing decompressive craniectomy versus craniotomy in patients with acute subdural hematoma. Neurosurg Rev 2024; 47:77. [PMID: 38336894 PMCID: PMC10858084 DOI: 10.1007/s10143-024-02292-5] [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: 12/15/2023] [Revised: 01/06/2024] [Accepted: 01/14/2024] [Indexed: 02/12/2024]
Abstract
There are two controversial surgery methods which are traditionally used: craniotomy and decompressive craniectomy. The aim of this study was to evaluate the efficacy and complications of DC versus craniotomy for surgical management in patients with acute subdural hemorrhage (SDH) following traumatic brain injury (TBI). We conducted a comprehensive search on PubMed, Scopus, Web of Science, and Embase up to July 30, 2023, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Relevant articles were reviewed, with a focus on studies comparing decompressive craniectomy to craniotomy techniques in patients with SDH following TBI. Ten studies in 2401 patients were reviewed. A total of 1170 patients had a craniotomy, and 1231 had decompressive craniectomy. The mortality rate was not significantly different between the two groups (OR: 0.46 [95% CI: 0.42-0.5] P-value: 0.07). The rate of revision surgery was insignificantly different between the two groups (OR: 0.59 [95% CI: 0.49-0.69] P-value: 0.08). No significant difference was found between craniotomy and decompressive craniectomy regarding unilateral mydriasis (OR: 0.46 [95% CI: 0.35-0.57] P-value < 0.001). However, the craniotomy group had significantly lower rates of non-pupil reactivity (OR: 0.27 [95% CI: 0.17-0.41] P-value < 0.001) and bilateral mydriasis (OR: 0.59 [95% CI: 0.5-0.66] P-value: 0.04). There was also no significant difference in extracranial injury between the two groups, although the odds ratio of significant extracranial injury was lower in the craniotomy group (OR: 0.58 [95% CI: 0.45-0.7] P-value: 0.22). Our findings showed that non-pupil and bilateral-pupil reactivity were significantly more present in decompressive craniectomy. However, there was no significant difference between the two groups regarding mortality rate, extracranial injury, revision surgery, and one-pupil reactivity.
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Affiliation(s)
- Mohammad Amin Habibi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Clinical Research Development Center, Qom University of Medical Sciences, Qom, Iran
| | - Andrew J Kobets
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | | | - Mehdi Mousavi Nasab
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pooria Sobhanian
- Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Seyed Ahmad Naseri Alavi
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA.
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Ran KR, Vattipally VN, Giwa GA, Myneni S, Raj D, Dardick JM, Rincon-Torroella J, Ye X, Byrne JP, Suarez JI, Lin SC, Jackson CM, Mukherjee D, Gallia GL, Huang J, Weingart JD, Azad TD, Bettegowda C. Craniotomy versus craniectomy for traumatic acute subdural hematoma-coarsened exact matched analysis of outcomes. J Clin Neurosci 2024; 119:52-58. [PMID: 37984187 DOI: 10.1016/j.jocn.2023.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/17/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Acute subdural hematoma (aSDH) after traumatic brain injury frequently requires emergent craniotomy (CO) or decompressive craniectomy (DC). We sought to determine the variables associated with either surgical approach and to compare outcomes between matched patients. METHODS A multi-center retrospective review was used to identify traumatic aSDH patients who underwent CO or DC. Patient variables independently associated with surgical approach were used for coarsened exact matching.Multivariate logistic regression and multivariate Cox proportional-hazards regression wereconducted on matched patients to determine independent predictors of mortality. RESULTS Seventy-six patients underwent CO and sixty-two underwent DC for aSDH evacuation. DC patients were21.4 years younger (P < 0.001), more likely to be male (80.6 % vs 60.5 %,P = 0.011), and present with GCS ≤ 8 (64.5 % vs 36.8 %,P = 0.001). Age (P < 0.001), epidural hematoma (P = 0.01), skull fracture (P = 0.001), and cisternal effacement (P = 0.02) were independently associated with surgical approach. After coarsened exact matching, DC (P = 0.008), older age (P = 0.007), male sex (P = 0.04), and intraventricular hemorrhage (P = 0.02), were independently associated with inpatient mortality. Multivariate Cox proportional-hazards regression demonstrated that DC was independently associated with mortality at 90-days (P = 0.001) and 1-year post-operation (P = 0.003). CONCLUSION aSDH patients who receive surgical evacuation via DC as opposed to CO are younger, more likely to be male, and have worse clinical exam. After controlling for patient differences via coarsened exact matching, DC is independently associated with mortality.
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Affiliation(s)
- Kathleen R Ran
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Vikas N Vattipally
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ganiat A Giwa
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Saket Myneni
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Divyaansh Raj
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M Dardick
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Xiaobu Ye
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James P Byrne
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jose I Suarez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shih-Chun Lin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jon D Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hanif S, Yousaf I, Iqbal M, Kumari U, Surani S. Brain herniation and subsequent complications following partial resection of high-grade glioma: A case report. Clin Case Rep 2024; 12:e8407. [PMID: 38173889 PMCID: PMC10762324 DOI: 10.1002/ccr3.8407] [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: 09/25/2023] [Revised: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
Key Clinical Message This case highlights the need for tailored strategies to address issues like brain herniation, subdural hygroma, and cerebrospinal fluid leak, which, if not managed promptly, can lead to long-term neurological deficits. Additionally, the role of specialized facilities in delivering highly specialized care for managing such intricate cases cannot be understated. Abstract Decompressive craniectomy-induced subdural hygroma (SDH) frequently coexists with external cerebral herniation, resulting in neurological impairments. The incidence of brain herniation through a craniectomy defect postoperatively is 25%. Brain herniation (BH), SDH, and cerebrospinal fluid leak require urgent neurosurgical management as they can lead to irreversible long-term neurological deficits. We report a case of a 42-year-old male who presented with headache and grand mal seizures. He was diagnosed with herniation of brain parenchyma through the surgical defect with a displacement of the bone flap by a heterogeneously enhancing lesion in the left parietal lobe along with SDH in the left frontoparietal region post partial resection of high-grade glioma. In this report, we discuss the pathogenesis and management strategies of brain herniation, wound infection, cerebrospinal fluid (CSF) leak, ipsilateral SDH, floating bone flap, and communicating hydrocephalus in an adult patient following partial resection of high-grade glioma. This particular case emphasizes the value of an individualized patient-centered surgical approach to minimize the risk of postoperative complications.
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Affiliation(s)
| | - Irfan Yousaf
- Shaukat Khanum Cancer Memorial HospitalLahorePakistan
| | - Maham Iqbal
- Department of medicineDow University Of Health SciencesKarachiPakistan
| | - Usha Kumari
- Dow University of Health SciencesKarachiPakistan
| | - Salim Surani
- Texas A&M UniversityCollege StationTexasUSA
- Mayo ClinicRochesterMinnesotaUSA
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Perlman R, Tsai K, Lo J. Trauma Anesthesiology Perioperative Management Update. Adv Anesth 2023; 41:143-162. [PMID: 38251615 DOI: 10.1016/j.aan.2023.06.003] [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: 01/23/2024]
Abstract
Anesthesia for patients with life-threatening injuries is an essential part of post-accident care. Unfortunately, there is variability in trauma anesthesia care and numerous nonstandardized methods of working with patients remain. Uncertainty exists as to when and how best to intubate trauma patients, the use of vasopressors, and the appropriate management of severe traumatic brain injury. Some physicians recommend prehospital rapid sequence intubation, whereas others use bag-mask ventilation at lower pressures with no cricoid pressure and early transport to a trauma center. Overall, the absence of uniformity in trauma anesthesia care underlines the need for continued study and dialogue to define best practices and optimize patient outcomes.
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Affiliation(s)
- Ryan Perlman
- Trauma Anesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA.
| | - Kevin Tsai
- Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
| | - Jessie Lo
- Trauma Education Program, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
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Szczygielski J, Hubertus V, Kruchten E, Müller A, Albrecht LF, Schwerdtfeger K, Oertel J. Prolonged course of brain edema and neurological recovery in a translational model of decompressive craniectomy after closed head injury in mice. Front Neurol 2023; 14:1308683. [PMID: 38053795 PMCID: PMC10694459 DOI: 10.3389/fneur.2023.1308683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/01/2023] [Indexed: 12/07/2023] Open
Abstract
Background The use of decompressive craniectomy in traumatic brain injury (TBI) remains a matter of debate. According to the DECRA trial, craniectomy may have a negative impact on functional outcome, while the RescueICP trial revealed a positive effect of surgical decompression, which is evolving over time. This ambivalence of craniectomy has not been studied extensively in controlled laboratory experiments. Objective The goal of the current study was to investigate the prolonged effects of decompressive craniectomy (both positive and negative) in an animal model. Methods Male mice were assigned to the following groups: sham, decompressive craniectomy, TBI and TBI followed by craniectomy. The analysis of functional outcome was performed at time points 3d, 7d, 14d and 28d post trauma according to the Neurological Severity Score and Beam Balance Score. At the same time points, magnetic resonance imaging was performed, and brain edema was analyzed. Results Animals subjected to both trauma and craniectomy presented the exacerbation of the neurological impairment that was apparent mostly in the early course (up to 7d) after injury. Decompressive craniectomy also caused a significant increase in brain edema volume (initially cytotoxic with a secondary shift to vasogenic edema and gliosis). Notably, delayed edema plus gliosis appeared also after decompression even without preceding trauma. Conclusion In prolonged outcomes, craniectomy applied after closed head injury in mice aggravates posttraumatic brain edema, leading to additional functional impairment. This effect is, however, transient. Treatment options that reduce brain swelling after decompression may accelerate neurological recovery and should be explored in future experiments.
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Affiliation(s)
- Jacek Szczygielski
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Instutute of Neuropathology, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Institute of Medical Sciences, University of Rzeszów, Rzeszow, Poland
| | - Vanessa Hubertus
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Department of Neurosurgery, Charité University Medicine, Berlin, Germany
- Berlin Institute of Health at Charité, Berlin, Germany
| | - Eduard Kruchten
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Institute of Interventional and Diagnostic Radiology, Karlsruhe, Germany
| | - Andreas Müller
- Department of Radiology, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Lisa Franziska Albrecht
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Karsten Schwerdtfeger
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
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Kölbel B, Novotny A, Willms A, Kehl V, Meyer B, Mauer UM, Krieg SM. Study protocol for a multicenter randomized controlled pilot study on decompressive laparotomy vs. decompressive craniectomy for intractable intracranial pressure after traumatic brain injury: The SCALPEL study. BRAIN & SPINE 2023; 3:102677. [PMID: 37822567 PMCID: PMC10562836 DOI: 10.1016/j.bas.2023.102677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/05/2023] [Accepted: 09/17/2023] [Indexed: 10/13/2023]
Abstract
Introduction Decompressive craniectomy (DC) is the ultimate intervention to lower intracranial pressure (ICP) following severe traumatic brain injury (TBI). However, this intervention is associated with considerable adverse events and a higher proportion of survivors with poor functional outcomes. Research question In a multicompartment system ICP is associated with intraabdominal pressure (IAP) due to cerebral venous outflow from the brain. This is the rationale for decompressive laparotomy (DL) to control ICP after TBI as reported by experimental and retrospective clinical data. The safety profile of DL is superior to DC. This study aims to randomly assign patients with intractable high ICP after severe TBI to DL or DC. Material and methods Among other inclusion criteria, ICP must be above 20 mmHg (1-12 h) despite sedation and all other measures according to current guidelines. The primary outcome is the Extended Glasgow Outcome Scale assessed after twelve months. Further secondary outcome measures are compartmental pressure values, complications, etc. After 20 initial patients, results will be reviewed by the ethics committees and safety monitoring board to decide on the enrolment of 80 additional patients. Results The study is designed to provide not only high-quality prospective data for the first time on this treatment approach, its two-stage design (20 + 80 pts) also provides maximum patient safety. This protocol conforms with the SPIRIT 2013 Statement. Ethics approval was granted by our but also 5 other university ethics committees (registration 473/18S). Conclusion Registration was performed prior to study initiation in November 2021 (registration number NCT05115929).
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Affiliation(s)
- Benny Kölbel
- Department of Surgery, Bundeswehrkrankenhaus Ulm, Germany
| | - Alexander Novotny
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Arnulf Willms
- Department of Surgery, Bundeswehrkrankenhaus Hamburg, Germany
| | - Victoria Kehl
- Münchner Studienzentrum, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Uwe-Max Mauer
- Department of Neurosurgery, Bundeswehrkrankenhaus Ulm, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Decraene B, Klein SP, Piper I, Gregson B, Enblad P, Ragauskas A, Citerio G, Chambers I, Neumann JO, Sahuquillo J, Kiening K, Moss L, Nilsson P, Donald R, Howells T, Lo M, Depreitere B. Decompressive craniectomy as a second/third-tier intervention in traumatic brain injury: A multicenter observational study. Injury 2023; 54:110911. [PMID: 37365094 DOI: 10.1016/j.injury.2023.110911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES RESCUEicp studied decompressive craniectomy (DC) applied as third-tier option in severe traumatic brain injury (TBI) patients in a randomized controlled setting and demonstrated a decrease in mortality with similar rates of favorable outcome in the DC group compared to the medical management group. In many centers, DC is being used in combination with other second/third-tier therapies. The aim of the present study is to investigate outcomes from DC in a prospective non-RCT context. METHODS This is a prospective observational study of 2 patient cohorts: one from the University Hospitals Leuven (2008-2016) and one from the Brain-IT study, a European multicenter database (2003-2005). In thirty-seven patients with refractory elevated intracranial pressure who underwent DC as a second/third-tier intervention, patient, injury and management variables including physiological monitoring data and administration of thiopental were analysed, as well as Extended Glasgow Outcome score (GOSE) at 6 months. RESULTS In the current cohorts, patients were older than in the surgical RESCUEicp cohort (mean 39.6 vs. 32.3; p < 0.001), had higher Glasgow Motor Score on admission (GMS < 3 in 24.3% vs. 53.0%; p = 0.003) and 37.8% received thiopental (vs. 9.4%; p < 0.001). Other variables were not significantly different. GOSE distribution was: death 24.3%; vegetative 2.7%; lower severe disability 10.8%; upper severe disability 13.5%; lower moderate disability 5.4%; upper moderate disability 2.7%, lower good recovery 35.1%; and upper good recovery 5.4%. The outcome was unfavorable in 51.4% and favorable in 48.6%, as opposed to 72.6% and 27.4% respectively in RESCUEicp (p = 0.02). CONCLUSION Outcomes in DC patients from two prospective cohorts reflecting everyday practice were better than in RESCUEicp surgical patients. Mortality was similar, but fewer patients remained vegetative or severely disabled and more patients had a good recovery. Although patients were older and injury severity was lower, a potential partial explanation may be in the pragmatic use of DC in combination with other second/third-tier therapies in real-life cohorts. The findings underscore that DC maintains an important role in managing severe TBI.
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Affiliation(s)
| | | | - Ian Piper
- Southern General Hospital, Glasgow, United Kingdom
| | | | | | | | | | - Iain Chambers
- James Cook University Hospital, Middlesbrough, United Kingdom
| | | | | | - Karl Kiening
- Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Laura Moss
- Southern General Hospital, Glasgow, United Kingdom
| | | | - Rob Donald
- Stats Research, Scotland, United Kingdom
| | | | - Milly Lo
- University of Edinburgh, Edinburgh, United Kingdom
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12
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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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13
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Wang Z, Zhang R, Han Z, Zhang Y, Wang J, Wang B, Liu B, Yang W. Intracranial peak pressure as a predictor for perioperative mortality after spontaneous intracerebral hemorrhage evacuation and decompressive craniectomy. Chin Neurosurg J 2023; 9:2. [PMID: 36653808 PMCID: PMC9847089 DOI: 10.1186/s41016-023-00316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND An optimal intracranial pressure (ICP) management target is not well defined in patients with spontaneous intracerebral hemorrhage. The aim of this study was to explore the association between perioperative ICP monitoring parameters and mortality of patients with spontaneous intracerebral hematoma undergoing emergency hematoma removal and decompressive craniectomy (DC), to provide evidence for a target-oriented ICP management. METHODS The clinical and radiological features of 176 consecutive patients with spontaneous intracerebral hemorrhage that underwent emergent hematoma evacuation and DC were reviewed. The Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) scores were assessed 2 weeks after surgery. Multivariate logistic regression analysis was performed to identify predictors for perioperative death. RESULTS Forty-four cases (25.0%) were assigned to the ICP group. In patients with an ICP monitor, the median peak ICP value was 25.5 mmHg; 50% of them had a peak ICP value of more than 25 mmHg. The median duration of ICP > 25 mmHg was 2 days. Without a target-specific ICP management, the mortality at 2 weeks after surgery was similar between patients with or without an ICP monitor (27.3% versus 18.2%, p = 0.20). In multivariable analysis, the peak ICP value (OR 1.11, 95% CI 1.004-1.234, p = 0.04) was significantly associated with perioperative death in the ICP group. The area under ROC curve of peak ICP value was 0.78 (95%CI 0.62-0.94) for predicting mortality, with a cut-off value of 31 mmHg. CONCLUSION Compared with a persistent hyperintracranial pressure, a high ICP peak value might provide a better prediction for the mortality of patients with spontaneous intracerebral hemorrhage evacuation and DC, suggesting a tailored ICP management protocol to decrease ICP peak value.
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Affiliation(s)
- Zhong Wang
- grid.440229.90000 0004 1757 7789Department of Neurosurgery, Inner Mongolia People’s Hospital, 20 ZhaoWooda Road, Hohhot, Inner Mongolia People’s Republic of China
| | - Ruijian Zhang
- grid.440229.90000 0004 1757 7789Department of Neurosurgery, Inner Mongolia People’s Hospital, 20 ZhaoWooda Road, Hohhot, Inner Mongolia People’s Republic of China
| | - Zhitong Han
- grid.440229.90000 0004 1757 7789Department of Neurosurgery, Inner Mongolia People’s Hospital, 20 ZhaoWooda Road, Hohhot, Inner Mongolia People’s Republic of China
| | - Yisong Zhang
- grid.440229.90000 0004 1757 7789Department of Neurosurgery, Inner Mongolia People’s Hospital, 20 ZhaoWooda Road, Hohhot, Inner Mongolia People’s Republic of China
| | - Junqing Wang
- grid.440229.90000 0004 1757 7789Department of Neurosurgery, Inner Mongolia People’s Hospital, 20 ZhaoWooda Road, Hohhot, Inner Mongolia People’s Republic of China
| | - Bo Wang
- grid.440229.90000 0004 1757 7789Department of Neurosurgery, Inner Mongolia People’s Hospital, 20 ZhaoWooda Road, Hohhot, Inner Mongolia People’s Republic of China
| | - Baiyu Liu
- grid.440229.90000 0004 1757 7789Department of Neurosurgery, Inner Mongolia People’s Hospital, 20 ZhaoWooda Road, Hohhot, Inner Mongolia People’s Republic of China
| | - Weiran Yang
- grid.440229.90000 0004 1757 7789Department of Neurosurgery, Inner Mongolia People’s Hospital, 20 ZhaoWooda Road, Hohhot, Inner Mongolia People’s Republic of China
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14
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Lim JX, Liu SJ, Cheong TM, Saffari SE, Han JX, Chen MW. Closure intracranial pressure is an objective intraoperative determinant of the adequacy of surgical decompression in traumatic acute subdural haematoma: a multicentre observational study. Acta Neurochir (Wien) 2022; 164:2741-2750. [PMID: 35831725 DOI: 10.1007/s00701-022-05270-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/06/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE Acute subdural haematoma (ASDH) is associated with severe traumatic brain injury and poor outcomes. Although guidelines exist for the decompression of ASDH, the question of adequate decompression remains unanswered. The authors examined the relationship of intracranial pressure (ICP) on closure with outcomes to determine its utility in the determination of adequate ASDH decompression. METHODS A multicentre retrospective review of 105 consecutive patients with ASDH who underwent decompressive surgery was performed. Receiver operating characteristic (ROC) analysis with internal validation was performed to determine an ICP threshold for the division of patients into the inadequate and good ICP groups. Multivariable analyses were performed for both inpatient and long-term outcomes. RESULTS An ICP threshold of 10 mmHg was identified with a 91.5% specificity, 45.7% sensitivity, and a positive and negative predictive value of 80.8% and 68.4%. There were 26 patients (24.8%) and 79 patients (75.2%) in the inadequate and good ICP groups, respectively. After adjustment, the inadequate ICP group was associated with increased postoperative usage of mannitol (OR 14.2, p < 0.001) and barbiturates (OR 150, p = 0.001). Inadequate ICP was also associated with increased inpatient mortality (OR 24.9, p < 0.001), and a lower rate of favourable MRS at 1 year (OR 0.08, p = 0.008). The complication rate was similar amongst the groups. CONCLUSIONS Closure ICP is a novel, objective, and actionable intraoperative biomarker that correlates with inpatient and long-term outcomes in ASDH. Various surgical manoeuvres can be undertaken to achieve this target safely. Large-scale prospective studies should be performed to validate this ICP threshold.
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Affiliation(s)
- Jia Xu Lim
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore.
| | - Sherry Jiani Liu
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Tien Meng Cheong
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Seyed Ehsan Saffari
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
- Centre for Quantitative Medicine, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Julian Xinguang Han
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Min Wei Chen
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
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15
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Second- and Third-Tier Therapies for Severe Traumatic Brain Injury. J Clin Med 2022; 11:jcm11164790. [PMID: 36013029 PMCID: PMC9410180 DOI: 10.3390/jcm11164790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022] Open
Abstract
Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.
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16
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Singh RD, van Dijck JTJM, Maas AIR, Peul WC, van Essen TA. Challenges Encountered in Surgical Traumatic Brain Injury Research: A Need for Methodological Improvement of Future Studies. World Neurosurg 2022; 161:410-417. [PMID: 35505561 DOI: 10.1016/j.wneu.2021.11.092] [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: 10/18/2021] [Accepted: 11/22/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Investigating neurosurgical interventions for traumatic brain injury (TBI) involves complex methodological and practical challenges. In the present report, we have provided an overview of the current state of neurosurgical TBI research and discussed the key challenges and possible solutions. METHODS The content of our report was based on an extensive literature review and personal knowledge and expert opinions of senior neurosurgeon researchers and epidemiologists. RESULTS Current best practice research strategies include randomized controlled trials (RCTs) and comparative effectiveness research. The performance of RCTs has been complicated by the heterogeneity of TBI patient populations with the associated sample size requirements, the traditional eminence-based neurosurgical culture, inadequate research budgets, and the often acutely life-threatening setting of severe TBI. Statistical corrections can mitigate the effects of heterogeneity, and increasing awareness of clinical equipoise and informed consent alternatives can improve trial efficiency. The substantial confounding by indication, which limits the interpretability of observational research, can be circumvented by using an instrumental variable analysis. Traditional TBI outcome measures remain relevant but do not adequately capture the subtleties of well-being, suggesting a need for multidimensional approaches to outcome assessments. CONCLUSIONS In settings in which traditional RCTs are difficult to conduct and substantial confounding by indication can be present, observational studies using an instrumental variable analysis and "pragmatic" RCTs are promising alternatives. Embedding TBI research into standard clinical practice should be more frequently considered but will require fundamental modifications to the current health care system. Finally, multimodality outcome assessment will be key to improving future surgical and nonsurgical TBI research.
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Affiliation(s)
- Ranjit D Singh
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands.
| | - Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
| | - Thomas A van Essen
- Department of Neurosurgery, University Neurosurgical Center Holland, Leiden University Medical Centre, Haaglanden Medical Center, and Haga Teaching Hospital, Leiden University, The Hague, The Netherlands
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17
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Zaed I, Safa A, Spennato P, Mottolese C, Chibbaro S, Cannizzaro D, Faggin R, Frassanito P, Maduri R, Messerer M, Servadei F. A Multicentric European Clinical Study on Custom-Made Porous Hydroxyapatite Cranioplasty in a Pediatric Population. Front Surg 2022; 9:848620. [PMID: 35402489 PMCID: PMC8983879 DOI: 10.3389/fsurg.2022.848620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Cranioplasty (CP) is a surgical intervention aiming to re-establish the integrity of skull defects. Autologous bone and different heterologous materials are used for this purpose, with various reported related complications, especially in children.This study aims to evaluate the rate of complication in a multicentric cohort of pediatric patients treated by porous hydroxyapatite (PHA) CP implantation and to assess the reliability of post-marketing clinical data collected by a manufacturing company. Methods The authors proactively collected clinical data from 20 institutions in different European countries for patients under the age of 16 treated with a PHA implant. The data were obtained by conducting an on-site interview with physicians in charge of the patients (Post-Marketing Surveillance, PMS group). The endpoints were the incidence of adverse events and related implant removal. The clinical data were compared to the company-based register including all patients under the age of 16 who received the same implant from January 1, 2004 to December 31, 2020, and the collecting complications voluntarily reported by surgeons (Database, DB group). Results The two groups were similar in terms of demographic characteristics and rate of complications. In the PMS group, a total of 11 (16.9%) complications were reported in the group of 65 patients that were proactively collected. Both fractures and infections were the most common complications with 4 cases each (6.2%). In the case of both infections and fractures, revision surgery was required for only one patient (1.5%). Three (4.5%) cases of displacements were reported, and in one (1.5%) case, a surgical revision was required, for a total of 3 (4.5%) cases requiring surgical revision. The average follow-up was 26.7 months. Conclusions Different from a previous study on adult age, pediatric neurosurgeons are more prone to report even to the manufacturing company complications related to skull reconstruction in children. Therefore, these data can be compared with those of other clinical studies. The PHA CP in this series of 65 patients presents a complication rate collected on-site that is similar to other heterologous materials.
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Affiliation(s)
- Ismail Zaed
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Adrian Safa
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Piero Spennato
- Division of Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Carmine Mottolese
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, Université Claude Bernard Lyon 1, Lyon, France
| | - Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
| | - Delia Cannizzaro
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Roberto Faggin
- Division of Pediatric Neurological Surgery, Department of Pediatrics, University of Padua, Padua, Italy
| | - Paolo Frassanito
- Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rodolfo Maduri
- Avaton Surgical Group, Clinique de Genolier, Swiss Medical Network, Genolier, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
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18
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Gantner D, Wiegers E, Bragge P, Finfer S, Delaney A, van Essen T, Peul WC, Maas A, Cooper DJ. Decompressive craniectomy practice following traumatic brain injury, in comparison with randomized trials. J Neurotrauma 2022; 39:860-869. [PMID: 35243877 DOI: 10.1089/neu.2021.0312] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
High quality evidence shows decompressive craniectomy (DC) following traumatic brain injury (TBI) may improve survival but increase the number of severely disabled survivors. Contemporary international practice is unknown. We sought to describe international use of DC, and the alignment with evidence and clinical practice guidelines, by analyzing the harmonized CENTER-TBI and OzENTER-TBI Core study datasets. These include patients admitted to ICUs in Europe, the United Kingdom and Australia between 2015 and 2017. Outcomes of interest were treatment with DC relative to clinical trial evidence and the Brain Trauma Foundation guidelines. Of 2336 people admitted to ICUs following TBI, DC was performed in 320 (13.7%): in 64/1422 (4.5%) patients with diffuse TBI, and 195/640 (30.5%) patients with traumatic mass lesions. Secondary DC (for treatment of intracranial hypertension) was used infrequently in patients who met enrolment criteria of the two randomised clinical trials informing the guidelines: in 11/124 (8.9%) of those matching DECRA enrolment, and in 30/224 (13.4%) of those matching RESCUEicp. Of patients who underwent DC 258/320 (80.6%) were ineligible for either trial: 149/320 (46.6%) underwent primary DC, 62/320 (19.4%) were outside the trials' age criteria, and 126/320 (39.4%) did not develop intracranial hypertension refractory to non-operative therapies prior to DC. Secondary DC was used infrequently in patients in whom it had been shown to be potentially harmful, indicating alignment between contemporaneous evidence and practice. However, most patients who underwent DC were ineligible for the key trials; whether they benefitted from DC remains unknown.
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Affiliation(s)
- Dashiell Gantner
- Monash University, 2541, Australian and New Zealand Intensive Care Research Centre, 553 St Kilda Rd, Melbourne, Victoria, Australia, 3004.,Alfred Health, 5392, Department of Intensive Care, 55 Commercial Rd, Melbourne, Victoria, Australia, 3004;
| | - Eveline Wiegers
- Erasmus University Rotterdam, 6984, Department of Public Health, Kortenaerstraat 22, J, Rotterdam, Zuid-Holland, Netherlands, 3012VD;
| | - Peter Bragge
- National Trauma Research Institute, 89 Commercial Road, Prahran, Melbourne, Victoria, Australia, 3004;
| | - Simon Finfer
- Royal North Shore Hospital, Intensive Care Unit, Pacific Highway, Sydney, New South Wales, Australia, 2076;
| | - Anthony Delaney
- The George Institute for Global Health, 211065, Newtown, New South Wales, Australia;
| | | | - Wilco C Peul
- Leiden University Medical Center, 4501, Neurosurgery, LUMC, Albinusdreef 2, Leiden, Holland, Netherlands, 2300 RC.,Medical Centre Haaglanden, 2901, Neurosurgery, Den Haag, Netherlands, 2501 CK;
| | - Andrew Maas
- University Hospital Antwerp, Neurosurgery, Wilrijkstraat 10, Edegem, Belgium, 2650.,Netherlands;
| | - D James Cooper
- The Alfred, Intensive Care, Commercial Road, Melbourne, Victoria, Australia, 3004.,Monash University, ANZIC-RC, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria, Australia, 3004;
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19
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Ammar R, Chelly H, Kolsi F, Smaoui M, Hamida CB, Bahloul M, Boudawara Z, Bouaziz M. Decompressive craniectomy after traumatic brain injury: An observational study of 147 patients admitted in a Tunisian ICU. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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20
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Beez T, Schuhmann MU, Frassanito P, Di Rocco F, Thomale UW, Bock HC. Protocol for the multicentre prospective paediatric craniectomy and cranioplasty registry (pedCCR) under the auspices of the European Society for Paediatric Neurosurgery (ESPN). Childs Nerv Syst 2022; 38:1461-1467. [PMID: 35532778 PMCID: PMC9325798 DOI: 10.1007/s00381-022-05540-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/21/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE In the paediatric age group, the overall degree of evidence regarding decompressive craniectomy (DC) and cranioplasty is low, whereas in adults, randomised controlled trials and prospective multicentre registries are available. To improve the evidence-based treatment of children, a consensus was reached to establish a prospective registry under the auspices of the European Society for Pediatric Neurosurgery (ESPN). METHODS This international multicentre prospective registry is aimed at collecting information on the indication, timing, technique and outcome of DC and cranioplasty in children. The registry will enrol patients ≤ 16 years of age at the time of surgery, irrespective of the underlying medical condition. The study design comprises four obligatory entry points as a core dataset, with an unlimited number of further follow-up entry points to allow documentation until adolescence or adulthood. Study centres should commit to complete data entry and long-term follow-up. RESULTS Data collection will be performed via a web-based portal (homepage: www.pedccr.com ) in a central anonymised database after local ethics board approval. An ESPN steering committee will monitor the project's progress, coordinate analyses of data and presentation of results at conferences and in publications on behalf of the study group. CONCLUSION The registry aims to define predictors for optimal medical care and patient-centred treatment outcomes. The ultimate goal of the registry is to generate results that are so relevant to be directly transferred into clinical practice to enhance treatment protocols.
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Affiliation(s)
- Thomas Beez
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-Universität, Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Martin U. Schuhmann
- grid.411544.10000 0001 0196 8249Pediatric Neurosurgery, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Paolo Frassanito
- grid.414603.4Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Federico Di Rocco
- grid.414103.3Service de Neurochirurgie Pédiatrique, Hôpital Femme Mère Enfant, Lyon, France
| | - Ulrich W. Thomale
- grid.6363.00000 0001 2218 4662Pediatric Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Hans Christoph Bock
- grid.411984.10000 0001 0482 5331Department of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
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21
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Controlled Decompression Attenuates Compressive Injury following Traumatic Brain Injury via TREK-1-Mediated Inhibition of Necroptosis and Neuroinflammation. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:4280951. [PMID: 34790287 PMCID: PMC8592713 DOI: 10.1155/2021/4280951] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/24/2021] [Indexed: 11/17/2022]
Abstract
Decompressive craniectomy is an effective strategy to reduce intracranial hypertension after traumatic brain injury (TBI), but it is related to many postoperative complications, such as delayed intracranial hematoma and diffuse brain swelling. Our previous studies have demonstrated that controlled decompression (CDC) surgery attenuates brain injury and reduces the rate of complications after TBI. Here, we investigated the potential molecular mechanisms of CDC in experimental models. The in vitro experiments were performed in a traumatic neuronal injury (TNI) model following compression treatment in primary cultured cortical neurons. We found that compression aggravates TNI-induced neuronal injury, which was significantly attenuated by CDC for 2 h or 3 h. The results of immunocytochemistry showed that CDC reduced neuronal necroptosis and activation of RIP3 induced by TNI and compression, with no effect on RIP1 activity. These protective effects were associated with decreased levels of inflammatory cytokines and preserved intracellular Ca2+ homeostasis. In addition, the expression of the two-pore domain K+ channel TREK-1 and its activity was increased by compression and prolonged by CDC. Treatment with the TREK-1 blockers, spadin or SID1900, could partially prevent the effects of CDC on intracellular Ca2+ metabolism, necroptosis, and neuronal injury following TNI and compression. Using a traumatic intracranial hypertension model in rats, we found that CDC for 20 min or 30 min was effective in alleviating brain edema and locomotor impairment in vivo. CDC significantly inhibited neuronal necroptosis and neuroinflammation and increased TREK-1 activation, and the CDC-induced protection in vivo was attenuated by spadin and SID1900. In summary, CDC is effective in alleviating compressive neuronal injury both in vitro and in vivo, which is associated with the TREK-1-mediated attenuation of intracellular Ca2+ overload, neuronal necroptosis, and neuroinflammation.
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22
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Meyer H, Khalid SI, Dorafshar AH, Byrne RW. The Materials Utilized in Cranial Reconstruction: Past, Current, and Future. Plast Surg (Oakv) 2021; 29:184-196. [PMID: 34568234 PMCID: PMC8436325 DOI: 10.1177/2292550320928560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cranioplasty (CP) is associated with high complication rates compared to other common neurosurgical procedures. Several graft materials are used for CP, which may contribute to the high complication rates, but data in the literature regarding the influence of graft material on post-CP outcomes are inconsistent making it difficult to determine if, when, and to what extent the graft material impacts the rate of perioperative complications. There is an increased demand to identify and develop superior graft materials. OBJECTIVE To review and compare the indications, risks, complications, and patient results associated with the use of different graft materials for cranial reconstructions. DESIGN A search through EBSCOhost was conducted using the keywords "craniectomy" or "decompressive craniectomy," "cranioplasty," and "materials." The search was limited to literature published in the English language from 2005 until the present. Ultimately, 69 articles were included in this review. Due to the heterogeneity of the study populations, results, statistical analyses, and collecting methods, no statistical analyses could be performed. CONCLUSIONS Several graft materials have been adapted for use in cranial reconstructions with inconsistent results making it unclear if or when one material may be indicated over others. Advances in computer-aided design have led to improved patient-specific implants, but the ideal graft material is still being sought after in ongoing research efforts. Reviewing materials currently available, as well as those in clinical trials, is important to identify the limitations associated with different implants and to guide future research.
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Affiliation(s)
- Haley Meyer
- Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, IL, USA
| | - Syed I. Khalid
- Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, IL, USA
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Amir H. Dorafshar
- Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL
| | - Richard W. Byrne
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL
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23
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Yang C, Huang X, Feng J, Xie L, Hui J, Li W, Jiang J. Prospective Randomized Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Hematoma (PREDICT-AEDH): study protocol for a randomized controlled trial. Trials 2021; 22:421. [PMID: 34187537 PMCID: PMC8244162 DOI: 10.1186/s13063-021-05359-6] [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: 03/11/2021] [Accepted: 06/07/2021] [Indexed: 11/27/2022] Open
Abstract
Background The expeditious surgical evacuation of acute epidural hematoma (AEDH) is an attainable gold standard and is often expected to have a good clinical outcome for patients with surgical indications. However, controversy exists on the optimal surgical options for AEDH, especially for patients with brain herniation. Neurosurgeons are confronted with the decision to evacuate the hematoma with decompressive craniectomy (DC) or craniotomy. Methods/design Patients of both sexes, age between 18 and 65 years, who presented to the emergency room with a clinical and radiological diagnosis of AEDH with herniation, were assessed against the inclusion and exclusion criteria to be enrolled in the study. Clinical and radiological information, including diagnosis of AEDH, treatment procedures, and follow-up data at 1, 3, and 6 months after injury, was collected from 120 eligible patients in 51 centers. The patients were randomized into groups of DC versus craniotomy in a 1:1 ratio. The primary outcome was the Glasgow Outcome Score-Extended (GOSE) at 6 months post-injury. Secondary outcomes included incidence of postoperative cerebral infarction, incidence of additional craniocerebral surgery, and other evaluation indicators within 6 months post-injury. Discussion This study is expected to support neurosurgeons in their decision to evacuate the epidural hematoma with or without a DC, especially in patients with brain herniation, and provide additional evidence to improve the knowledge in clinical practice. Trial registration ClinicalTrials.govNCT 04261673. Registered on 04 February 2020
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Affiliation(s)
- Chun Yang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China.,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Xianjian Huang
- Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Shenzhen, Guangdong, People's Republic of China
| | - Junfeng Feng
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China.,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, 227 Chongqing South Road, Shanghai, People's Republic of China
| | - Jiyuan Hui
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China.,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Weiping Li
- Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Shenzhen, Guangdong, People's Republic of China.
| | - Jiyao Jiang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China. .,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China.
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24
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Shah DB, Paudel P, Joshi S, Karki P, Sharma GR. Outcome of Decompressive Craniectomy for Traumatic Brain Injury: An Institutional-Based Analysis from Nepal. Asian J Neurosurg 2021; 16:288-293. [PMID: 34268153 PMCID: PMC8244698 DOI: 10.4103/ajns.ajns_392_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/25/2020] [Accepted: 03/16/2021] [Indexed: 11/11/2022] Open
Abstract
Objective: Decompressive craniectomy (DC) is one of the commonly used treatment modalities for refractory intracranial hypertension after traumatic brain injury. The objective of this study is to assess the functional outcome following DC in closed traumatic brain injury based on Glasgow Outcome Scale (GOS). Materials and Methods: This is a retrospective study conducted at Nepal Mediciti Hospital, Nepal, from September 2017 to October 2019. Data of the patients who had undergone DC for closed traumatic brain injury were reviewed from medical record files. Patients who had DC for nontraumatic causes were excluded from the study. Functional outcome was assessed using GOS at 3 months of follow-up. Results: Of the 52 decompressive craniectomies, 46 were included in the study. The majority was male (71.7%). The mean age and the mean Glasgow Coma Scale (GCS) score at presentation were 41.87 (standard deviation [SD] ± 15.29) and 7.59 (SD ± 2.97), respectively. The most common mode of injury was road traffic accident (76.1%). 60.9% had GCS score ≤8 while 39.1% had >8 GCS on admission. 34.8% had both the pupils reactive while 58.7% were anisocoric. Majority had Marshall IV and above grade of injury (67.4%). Sixteen (34.8%) had inhospital mortality. Favorable outcome was seen in 39.1%. GCS score >8 at presentation (72.2%, P < 0.001), bilaterally intact pupillary reflexes (75%, P < 0.001), Marshall grade injury ≤3 on computed tomography scan (90%, P < 0.001), and age <50 years (50%, P = 0.039) were significantly associated with favorable outcome. Procedure-related complications were seen in 36.9%. Conclusion: Favorable outcome was seen in 39.1%. Age <50 years, higher GCS score at presentation (>8), intact pupillary reflexes, and lower Marshall grade injuries were associated with favorable outcome. We recommend a larger prospective study to assess the long-term functional outcome after DC using extended GOS.
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Affiliation(s)
| | - Prakash Paudel
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Sumit Joshi
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Prasanna Karki
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
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25
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Sun W, Dong X, Yu G, Shuai L, Yuan Y, Ma C. Transcranial direct current stimulation in patients after decompressive craniectomy: a finite element model to investigate factors affecting the cortical electric field. J Int Med Res 2021; 49:300060520942112. [PMID: 33788619 PMCID: PMC8020252 DOI: 10.1177/0300060520942112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To simulate the process of transcranial direct current stimulation (tDCS) on
patients after decompressive craniectomy (DC), and to model cortical
electric field distributions under different electrode montages, we
constructed a finite element model that represented the human head at high
resolution. Methods Using computed tomography images, we constructed a human head model with high
geometrical similarity. The removed bone flap was simplified to be circular
with a diameter of 12 cm. We then constructed finite element models
according to bioelectrical parameters. Finally, we simulated tDCS on the
finite element models under different electrode montages. Results Inward current had a linear relationship with peak electric field value, but
almost no effect on electric field distribution. If the anode was not over
the skull hole (configuration 2), there was almost no difference in electric
field magnitude and focality between the circular and square electrodes.
However, if the anode was right over the hole (configuration 1), the
circular electrodes led to higher peak electric field values and worse
focality. In addition, configuration 1 significantly decreased focality
compared with configuration 2. Conclusion Our results might serve as guidelines for selecting current and electrode
montage settings when performing tDCS on patients after DC.
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Affiliation(s)
- Weiming Sun
- Institute of Life Science, Nanchang University, Nanchang,
Jiangxi Province, China
- School of Life Science, Nanchang University, Nanchang, Jiangxi
Province, China
- Department of Rehabilitation Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
- Yefeng Yuan, Department of Psychosomatic
Medicine, The First Affiliated Hospital of Nanchang University, No.17,
yongwaizheng street, Donghu District, Nanchang , Jiangxi Province 330006, China.
Chaolin Ma, Institute of Life Science,
Nanchang University, No. 999, xuefu road, Honggutan District, Nanchang, Jiangxi
Province 33003, China.
| | - Xiangli Dong
- Department of Psychosomatic Medicine, The Second Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Guohua Yu
- Department of Rehabilitation Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Lang Shuai
- Department of Rehabilitation Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Yefeng Yuan
- Department of Psychosomatic Medicine, The First Affiliated
Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Chaolin Ma
- Institute of Life Science, Nanchang University, Nanchang,
Jiangxi Province, China
- School of Life Science, Nanchang University, Nanchang, Jiangxi
Province, China
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Vilcinis R, Bunevicius A, Piliponis L, Tamasauskas A. Influence of Decompressive Craniectomy Post Evacuation of Epidural Hematoma in Comatose Patients. World Neurosurg 2021; 151:e753-e759. [PMID: 33945890 DOI: 10.1016/j.wneu.2021.04.109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Epidural hematoma causing brain herniation is a major cause of mortality and morbidity after severe traumatic brain injury, even if surgical treatment is performed quickly. Decompression may be effective in decreasing intracranial pressure, but its effect on outcomes remains unclear. METHODS A retrospective analysis of deeply comatose patients (Glasgow Coma Scale score 3-5) who underwent surgical treatment during a 12-year period, either via osteoplastic craniotomy (OC) or decompressive craniectomy, was carried out. Patient groups were compared on the basis of demographics, admission clinical state, head computed tomography imaging characteristics, and discharge outcome. RESULTS A total of 60 patients were examined. The first group of 31 patients (52%) needed decompression during primary surgery. The second group of 29 patients (48%) underwent OC with evacuation of epidural hematoma without decompression. Both patient groups were similar according to age (40.9 ± 13 vs. 40.6 ± 12.5 years), Glasgow Coma Scale score before surgery (4 [3-5] vs. 4 [3-5]), hematoma thickness (based on computed tomography) (3.44 ± 1 vs. 3.36 ± 1.62 cm), and midline shift (1.42 ± 0.83 vs. 1.36 ± 0.9 cm). Mortality was more evident in the decompression group (45.2% vs. 13.8%; P = 0.008), and the Glasgow Outcome Score was also lower, 2.26 ± 1.5 versus 3.45 ± 1.5 (P = 0.003). CONCLUSIONS Decompressive craniectomy following the evacuation of an acute epidural hematoma in deeply comatose patients demonstrated inferior outcomes in comparison with OC. Brain injury in the decompressive craniectomy patient group was more severe (concomitant subdural hematoma, early brain ischemia, and early brain herniation), which may have influenced the outcome. Further prospective studies are needed.
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Affiliation(s)
- Rimantas Vilcinis
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Adomas Bunevicius
- Neurosciences Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Lukas Piliponis
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Arimantas Tamasauskas
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Neurosciences Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania
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27
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Craniotomy size for traumatic acute subdural hematomas in elderly patients-same procedure for every age? Neurosurg Rev 2021; 45:459-465. [PMID: 33900496 PMCID: PMC8827226 DOI: 10.1007/s10143-021-01548-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/25/2021] [Accepted: 04/12/2021] [Indexed: 12/03/2022]
Abstract
Surgical treatment of acute subdural hematoma (aSDH) is still matter of debate, especially in the elderly. A retrospective study to compare two different surgical approaches, namely standard (SC, craniotomy size > 8 cm) and limited craniotomy (LC, craniotomy size < 8 cm), was conducted in elderly patients with traumatic aSDH to identify the role of craniotomy size in terms of clinical and radiological outcome. Sixty-four patients aged 75 or older with aSDH as sole lesion were retrospectively analyzed. Data were collected pre- and postoperatively including clinical and radiological criteria. The primary outcome parameter was 30-day mortality. Secondary outcome parameters were radiological. The mean age was 79.2 (± 3.1) years with no difference between groups and almost equal distribution of craniotomy size. Mortality rate was significantly higher in the SC group in comparison to the LC group (68.4% vs. 31.6%; p = 0.045). The preoperative HD (p = 0.08) and the MLS (p = 0.09) were significantly higher in the SC group, whereas postoperative radiological evaluation showed no significant difference in HD or MLS. A limited craniotomy is sufficient for adequate evacuation of an aSDH in the elderly achieving the same radiological and clinical outcome.
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28
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Cui W, Ge S, Shi Y, Wu X, Luo J, Lui H, Zhu G, Guo H, Feng D, Qu Y. Death after discharge: prognostic model of 1-year mortality in traumatic brain injury patients undergoing decompressive craniectomy. Chin Neurosurg J 2021; 7:24. [PMID: 33879254 PMCID: PMC8058982 DOI: 10.1186/s41016-021-00242-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/31/2021] [Indexed: 11/21/2022] Open
Abstract
Background Despite advances in decompressive craniectomy (DC) for the treatment of traumatic brain injury (TBI), these patients are at risk of having a poor long-term prognosis. The aim of this study was to predict 1-year mortality in TBI patients undergoing DC using logistic regression and random tree models. Methods This was a retrospective analysis of TBI patients undergoing DC from January 1, 2015, to April 25, 2019. Patient demographic characteristics, biochemical tests, and intraoperative factors were collected. One-year mortality prognostic models were developed using multivariate logistic regression and random tree algorithms. The overall accuracy, sensitivity, specificity, and area under the receiver operating characteristic curves (AUCs) were used to evaluate model performance. Results Of the 230 patients, 70 (30.4%) died within 1 year. Older age (OR, 1.066; 95% CI, 1.045–1.087; P < 0.001), higher Glasgow Coma Score (GCS) (OR, 0.737; 95% CI, 0.660–0.824; P < 0.001), higher d-dimer (OR, 1.005; 95% CI, 1.001–1.009; P = 0.015), coagulopathy (OR, 2.965; 95% CI, 1.808–4.864; P < 0.001), hypotension (OR, 3.862; 95% CI, 2.176–6.855; P < 0.001), and completely effaced basal cisterns (OR, 3.766; 95% CI, 2.255–6.290; P < 0.001) were independent predictors of 1-year mortality. Random forest demonstrated better performance for 1-year mortality prediction, which achieved an overall accuracy of 0.810, sensitivity of 0.833, specificity of 0.800, and AUC of 0.830 on the testing data compared to the logistic regression model. Conclusions The random forest model showed relatively good predictive performance for 1-year mortality in TBI patients undergoing DC. Further external tests are required to verify our prognostic model.
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Affiliation(s)
- Wenxing Cui
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Yingwu Shi
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Xun Wu
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Jianing Luo
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Haixiao Lui
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Gang Zhu
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Hao Guo
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Dayun Feng
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, No. 569 Xin Si Road, Xi'an, 710038, Shaanxi Province, China.
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Abouhashem S, Albakry A, El-Atawy S, Fawzy F, Elgammal S, Khattab O. Prediction of early mortality after primary decompressive craniectomy in patients with severe traumatic brain injury. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-020-00096-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objectives
Traumatic brain injury (TBI) is a worldwide major health problem associated with a high rate of morbidity and mortality. Intracranial hypertension following TBI is the main but not the only cause of early mortality. Decompressive craniectomy (DC) is used to decrease the intracranial pressure (ICP) and prevent brain herniation following TBI; however, the clinical outcome after DC for patients with TBI generates continuous debate. Prediction of early mortality after DC will help in making the surgery decision.
The aim of this study is to predict early mortality after DC based on the initial clinical and radiological findings.
Methods
In this study, 104 patients with severe traumatic brain injury have been treated by decompressive craniectomy and were retrospectively analyzed. Patients were divided into two groups; group I involved 32 patients who died within 28 days while group II involved 72 patients who survived after 28 days. The relationship between initial Glasgow Coma Scale score (GCS), pupil size and reactivity, associated injuries, and radiological findings were analyzed as predictor factors for early mortality.
Results
A total of 104 patients with severe TBI have been treated by DC and were analyzed; the early mortality occurred in 32 patients, 30.77%. There is a significant difference between groups in gender, mean GCS, Marshall scale, presence of isochoric pupils, and lung injury.
After stratification, odds of early mortality increases with the lower GCS, higher Marshall scale, lung injury, and abdominal injury while male gender and the presence of isochoric pupils decrease the odds of mortality. After univariate regression, the significant impact of GCS disappears except for GCS-8 which decreases the odds of mortality in comparison to other GCS scores while higher Marshall scale, presence of isochoric pupils, and lung injury increase the odds of mortality, but most of these effects disappear after multiple regressions except for lung injury and isochoric pupils.
Conclusion
Prediction of early mortality after DC is multifactorial, but the odds of early mortality after decompressive craniectomy in severe traumatic brain injury are progressively increased with the lower GCS, higher Marshall scale, and the presence of lung or abdominal injury.
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30
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Behranwala R, Aojula N, Hagana A, Houbby N, de Preux DL. An economic evaluation for the use of decompressive craniectomy in the treatment of refractory traumatic intracranial hypertension. Brain Inj 2021; 35:444-452. [PMID: 33529095 DOI: 10.1080/02699052.2021.1878556] [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: 10/22/2022]
Abstract
Objectives: The management of intracranial hypertension is a primary concern following traumatic brain injury. Data from recent randomized controlled trials have indicated that decompressive craniectomy results in some improved clinical outcomes compared to medical treatment for patients with refractory intracranial hypertension post-traumatic brain injury (TBI). This economic evaluation aims to assess the cost-effectiveness of decompressive craniectomy as a last-tier intervention for refractory intracranial hypertension from the perspective of the National Health Service (NHS).Methods: A Markov model was used to present the results from an international, multicentre, parallel-group, superiority, randomized trial. A cost-utility analysis was then carried out over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling.Results: The cost-utility analysis produced an incremental cost-effectiveness ratio (ICER) of £96,155.67 per QALY. This means that for every additional QALY gained by treating patients with decompressive craniectomy, a cost of £96,155.67 is incurred to the NHS.Conclusions: The ICER calculated is above the National Institute for Health and Care Excellence (NICE) threshold of £30,000 per QALY. This indicates that decompressive craniectomy is not a cost-effective first treatment option for refractory intracranial hypertension and maximum medical management is preferable initially.
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Affiliation(s)
| | - Nivaran Aojula
- Faculty of Medicine, Imperial College London, London, UK
| | - Arwa Hagana
- Faculty of Medicine, Imperial College London, London, UK
| | - Nour Houbby
- Faculty of Medicine, Imperial College London, London, UK
| | - Dr Laure de Preux
- Department of Economics and Public Policy, Imperial College London, Business School, London, UK
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Hanko M, Grendár M, Snopko P, Opšenák R, Šutovský J, Benčo M, Soršák J, Zeleňák K, Kolarovszki B. Random Forest-Based Prediction of Outcome and Mortality in Patients with Traumatic Brain Injury Undergoing Primary Decompressive Craniectomy. World Neurosurg 2021; 148:e450-e458. [PMID: 33444843 DOI: 10.1016/j.wneu.2021.01.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/01/2021] [Accepted: 01/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Various prognostic models are used to predict mortality and functional outcome in patients after traumatic brain injury with a trend to incorporate machine learning protocols. None of these models is focused exactly on the subgroup of patients indicated for decompressive craniectomy. Evidence regarding efficiency of this surgery is still incomplete, especially in patients undergoing primary decompressive craniectomy with evacuation of traumatic mass lesions. METHODS In a prospective study with a 6-month follow-up period, we assessed postoperative outcome and mortality of 40 patients who underwent primary decompressive craniectomy for traumatic brain injuries during 2018-2019. The results were analyzed in relation to a wide spectrum of preoperatively available demographic, clinical, radiographic, and laboratory data. Random forest algorithms were trained for prediction of both mortality and unfavorable outcome, with their accuracy quantified by area under the receiver operating curves (AUCs) for out-of-bag samples. RESULTS At the end of the follow-up period, we observed mortality of 57.5%. Favorable outcome (Glasgow Outcome Scale [GOS] score 4-5) was achieved by 30% of our patients. Random forest-based prediction models constructed for 6-month mortality and outcome reached a moderate predictive ability, with AUC = 0.811 and AUC = 0.873, respectively. Random forest models trained on handpicked variables showed slightly decreased AUC = 0.787 for 6-month mortality and AUC = 0.846 for 6-month outcome and increased out-of-bag error rates. CONCLUSIONS Random forest algorithms show promising results in prediction of postoperative outcome and mortality in patients undergoing primary decompressive craniectomy. The best performance was achieved by Classification Random forest for 6-month outcome.
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Affiliation(s)
- Martin Hanko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic.
| | - Marián Grendár
- Bioinformatic Center, Biomedical Center Martin (BioMed), Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Pavol Snopko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - René Opšenák
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Juraj Šutovský
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Martin Benčo
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Jakub Soršák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
| | - Branislav Kolarovszki
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Martin, Slovak Republic
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32
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Yang C, Zhang JR, Zhu G, Guo H, Gao F, Wang B, Cui WX, Shi YW, Du Y, Li ZH, Wang L, Ma LT, Qu Y, Ge SN. Effects of Primary Decompressive Craniectomy on the Outcomes of Serious Traumatic Brain Injury with Mass Lesions, and Independent Predictors of Operation Decision. World Neurosurg 2021; 148:e396-e405. [PMID: 33422716 DOI: 10.1016/j.wneu.2020.12.158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although operative indications for traumatic brain injury (TBI) are known, neurosurgeons are unsure whether to remove the bone flap after mass lesion extraction, and an efficient scoring system for predicting which patients should undergo decompressive craniectomy (DC) does not exist. METHODS Nine parameters were assessed. In total, 245 patients with severe TBI were retrospectively assessed from June 2015 to May 2019, who underwent DC or craniotomy to remove mass lesions. The 6-month mortality and Extended Glasgow Outcome Scale scores were compared between the DC and craniotomy groups. Using univariable and multivariable logistic regression equations, receiver operating characteristic curves were obtained for predicting the decision for DC. RESULTS The overall 6-month mortality in the entire cohort was 11.43% (28/245). Patients undergoing DC had lower mean preoperative Glasgow Coma Scale scores (P = 0.01), and higher amounts of individuals with a Glasgow Coma Scale score of 6 (P = 0.007), unresponsive pupillary light reflex (P < 0.001), closed basal cisterns (P < 0.001), and diffuse injury (P = 0.025), compared with the craniotomy group. Because of high disease severity, individuals administered primary DC showed increased 6-month mortality compared with the craniotomy group. However, in surviving patients, favorable Extended Glasgow Outcome Scale rates were similar in both groups. Pupillary light reflex and basal cisterns were independent predictors of the DC decision. Based on receiver operating characteristic curves, the model had sensitivity and specificity of 81.6% and 84.9%, respectively, in predicting the probability of DC. CONCLUSIONS These preliminary data showed that primary DC may benefit some patients with severe TBI with mass lesions. In addition, unresponsive preoperative pupil reaction and closed basal cistern could predict the DC decision.
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Affiliation(s)
- Chen Yang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China; Postdoctoral Research Station of Neurosurgery, General Hospital of Central Theater Command of Chinese People's Liberation Army, Wuhan, Hubei, China
| | - Jia-Rui Zhang
- The Helmholtz Sino-German Laboratory for Cancer Research, Department of Pathology, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Gang Zhu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hao Guo
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Fei Gao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bao Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Wen-Xing Cui
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Ying-Wu Shi
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yong Du
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhi-Hong Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Liang Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Lian-Ting Ma
- Postdoctoral Research Station of Neurosurgery, General Hospital of Central Theater Command of Chinese People's Liberation Army, Wuhan, Hubei, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shun-Nan Ge
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China.
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Ota HCU, Smith BG, Alamri A, Robertson FC, Marcus H, Hirst A, Broekman M, Hutchinson P, McCulloch P, Kolias A. The IDEAL framework in neurosurgery: a bibliometric analysis. Acta Neurochir (Wien) 2020; 162:2939-2947. [PMID: 32651707 PMCID: PMC7593304 DOI: 10.1007/s00701-020-04477-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/29/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The Idea, Development, Exploration, Assessment and Long-term study (IDEAL) framework was created to provide a structured way for assessing and evaluating novel surgical techniques and devices. OBJECTIVES The aim of this paper was to investigate the utilization of the IDEAL framework within neurosurgery, and to identify factors influencing implementation. METHODS A bibliometric analysis of the 7 key IDEAL papers on Scopus, PubMed, Embase, Web of Science, and Google Scholar databases (2009-2019) was performed. A second journal-specific search then identified additional papers citing the IDEAL framework. Publications identified were screened by two independent reviewers to select neurosurgery-specific articles. RESULTS The citation search identified 1336 articles. The journal search identified another 16 articles. Following deduplication and review, 51 relevant articles remained; 14 primary papers (27%) and 37 secondary papers (73%). Of the primary papers, 5 (36%) papers applied the IDEAL framework to their research correctly; two were aligned to the pre-IDEAL stage, one to the Idea and Development stages, and two to the Exploration stage. Of the secondary papers, 21 (57%) explicitly discussed the IDEAL framework. Eighteen (86%) of these were supportive of implementing the framework, while one was not, and two were neutral. CONCLUSION The adoption of the IDEAL framework in neurosurgery has been slow, particularly for early-stage neurosurgical techniques and inventions. However, the largely positive reviews in secondary literature suggest potential for increased use that may be achieved with education and publicity.
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Affiliation(s)
| | - Brandon G Smith
- Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - Alexander Alamri
- Department of Neurosurgery, The Royal London Hospital, London, UK
| | - Faith C Robertson
- Department. of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hani Marcus
- The Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Allison Hirst
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford and John Radcliffe Hospital, Oxford, UK
| | - Marike Broekman
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford and John Radcliffe Hospital, Oxford, UK
- Department of Neurosurgery, Haaglanden Medical Center/Leiden University Medical Center, The Hague, Netherlands
| | - Peter Hutchinson
- Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - Peter McCulloch
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford and John Radcliffe Hospital, Oxford, UK
| | - Angelos Kolias
- Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK.
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford and John Radcliffe Hospital, Oxford, UK.
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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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Zaed I, Rossini Z, Faedo F, Fontanella MM, Cardia A, Servadei F. Long-term follow-up of custom-made porous hydroxyapatite cranioplasty in adult patients: a multicenter European study. Can we trust self-reported complications? J Neurosurg Sci 2020; 66:335-341. [PMID: 32989979 DOI: 10.23736/s0390-5616.20.05138-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cranioplasty is a surgical intervention aiming to re-establish the integrity of skull defects. Autologous bone and different heterologous materials are used for this purpose, with various reported related complications. The aim of the study was to evaluate the complication rate in a multicentric cohort of patients underwent porous hydroxyapatite (PHA) cranioplasty implantation and to assess the validity of company post-market clinical analysis. METHODS Authors analyzed a company based register of 6279 PHA cranioplasty implanted all over the world. In these adult patients only self-reported complications were available. We then obtained the data of adult patients treated with custom-made porous HA prostheses (CustomBone Service) in 20 institutions from different European countries through an on-site interview with the physicians in charge of the patients (494 patients). The endpoints were the incidence of adverse events and of related implant removal. RESULTS The groups of patients had similar demographics characteristics. The average follow-up was 26.7 months. A significantly higher number of complications was recorded in the group of patients underwent onsite interview. Thirty-nine complications were reported (7.89%) with an explantation rate of 4.25% (21 cases) in the series, compared to the data reported from the Company (complications rate of 3.3% and explantation rate of 3.1%). The most common complications were infection (4.86%), hematomas (1.22%), fractures (1.01%), mobilization (0.4%) and scar retraction (0.4%). CONCLUSIONS Our data confirm that porous HA cranioplasty is at least as effective as other heterologous materials to repair cranial defects. Another interesting finding is that self-reporting complicantions by surgeons does not give a precise picture of the real rate of complications of the devices. These data in future studies need to be re-confirmed with on-site interviews.
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Affiliation(s)
- Ismail Zaed
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy - .,Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy -
| | - Zefferino Rossini
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Francesca Faedo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Marco M Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Cardia
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy
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STING-Mediated Autophagy Is Protective against H 2O 2-Induced Cell Death. Int J Mol Sci 2020; 21:ijms21197059. [PMID: 32992769 PMCID: PMC7582849 DOI: 10.3390/ijms21197059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022] Open
Abstract
Stimulator of interferon genes (STING)-mediated type-I interferon signaling is a well characterized instigator of the innate immune response following bacterial or viral infections in the periphery. Emerging evidence has recently linked STING to various neuropathological conditions, however, both protective and deleterious effects of the pathway have been reported. Elevated oxidative stress, such as neuroinflammation, is a feature of a number of neuropathologies, therefore, this study investigated the role of the STING pathway in cell death induced by elevated oxidative stress. Here, we report that the H2O2-induced activation of the STING pathway is protective against cell death in wildtype (WT) MEFSV40 cells as compared to STING−/− MEF SV40 cells. This protective effect of STING can be attributed, in part, to an increase in autophagy flux with an increased LC3II/I ratio identified in H2O2-treated WT cells as compared to STING−/− cells. STING−/− cells also exhibited impaired autophagic flux as indicated by p62, LC3-II and LAMP2 accumulation following H2O2 treatment, suggestive of an impairment at the autophagosome-lysosomal fusion step. This indicates a previously unrecognized role for STING in maintaining efficient autophagy flux and protecting against H2O2-induced cell death. This finding supports a multifaceted role for the STING pathway in the underlying cellular mechanisms contributing to the pathogenesis of neurological disorders.
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Lilja-Cyron A, Andresen M, Kelsen J, Andreasen TH, Fugleholm K, Juhler M. Long-Term Effect of Decompressive Craniectomy on Intracranial Pressure and Possible Implications for Intracranial Fluid Movements. Neurosurgery 2020; 86:231-240. [PMID: 30768137 DOI: 10.1093/neuros/nyz049] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/29/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) is used in cases of severe intracranial hypertension or impending intracranial herniation. DC effectively lowers intracranial pressure (ICP) but carries a risk of severe complications related to abnormal ICP and/or cerebrospinal fluid (CSF) circulation, eg, hygroma formation, hydrocephalus, and "syndrome of the trephined." OBJECTIVE To study the long-term effect of DC on ICP, postural ICP regulation, and intracranial pulse wave amplitude (PWA). METHODS Prospective observational study including patients undergoing DC during a 12-mo period. Telemetric ICP sensors (Neurovent-P-tel; Raumedic, Helmbrechts, Germany) were implanted in all patients. Following discharge from the neuro intensive care unit (NICU), scheduled weekly ICP monitoring sessions were performed during the rehabilitation phase. RESULTS A total of 16 patients (traumatic brain injury: 7, stroke: 9) were included (median age: 55 yr, range: 19-71 yr). Median time from NICU discharge to cranioplasty was 48 d (range: 16-98 d) and during this period, mean ICP gradually decreased from 7.8 ± 2.0 mm Hg to -1.8 ± 3.3 mm Hg (P = .02). The most pronounced decrease occurred during the first month. Normal postural ICP change was abolished after DC for the entire follow-up period, ie, there was no difference between ICP in supine and sitting position (P = .67). PWA was markedly reduced and decreased from initially 1.2 ± 0.7 mm Hg to 0.4 ± 0.3 mm Hg (P = .05). CONCLUSION Following NICU discharge, ICP decreases to negative values within 4 wk, normal postural ICP regulation is lost and intracranial PWA is diminished significantly. These abnormalities might have implications for intracranial fluid movements (eg, CSF and/or glymphatic flow) following DC and warrants further investigations.
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Affiliation(s)
| | - Morten Andresen
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kelsen
- Department of Orthopedic Surgery (Spine Section), Rigshospitalet, Copenhagen, Denmark
| | | | - Kåre Fugleholm
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
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Beydoun HA, Butt C, Beydoun MA, Eid SM, Zonderman AB, Johnstone B. Two latent classes of diagnostic and treatment procedures among traumatic brain injury inpatients. Sci Rep 2020; 10:10825. [PMID: 32616834 PMCID: PMC7331666 DOI: 10.1038/s41598-020-67576-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/26/2020] [Indexed: 11/26/2022] Open
Abstract
To characterize latent classes of diagnostic and/or treatment procedures among hospitalized U.S. adults, 18-64 years, with primary diagnosis of TBI from 2004-2014 Nationwide Inpatient Samples, latent class analysis (LCA) was applied to 10 procedure groups and differences between latent classes on injury, patient, hospital and healthcare utilization outcome characteristics were modeled using multivariable regression. Using 266,586 eligible records, LCA resulted in two classes of hospitalizations, namely, class I (n = 217,988) (mostly non-surgical) and class II (n = 48,598) (mostly surgical). Whereas orthopedic procedures were equally likely among latent classes, skin-related, physical medicine and rehabilitation procedures as well as behavioral health procedures were more likely among class I, and other types of procedures were more likely among class II. Class II patients were more likely to have moderate-to-severe TBI, to be admitted on weekends, to urban, medium-to-large hospitals in Midwestern, Southern or Western regions, and less likely to be > 30 years, female or non-White. Class II patients were also less likely to be discharged home and necessitated longer hospital stays and greater hospitalization charges. Surgery appears to distinguish two classes of hospitalized patients with TBI with divergent healthcare needs, informing the planning of healthcare services in this target population.
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Affiliation(s)
- Hind A Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, VA, 22060, USA.
| | - Catherine Butt
- Intrepid Spirit Center, Defense and Veterans Brain Injury Center, Fort Belvoir, VA, USA
| | - May A Beydoun
- Laboratory of Epidemiology and Population Sciences, National Institute On Aging, NIA/NIH/IRP, Baltimore, MD, USA
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alan B Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute On Aging, NIA/NIH/IRP, Baltimore, MD, USA
| | - Brick Johnstone
- Intrepid Spirit Center, Defense and Veterans Brain Injury Center, Fort Belvoir, VA, USA
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Barrel Stave Osteotomy Decompression for Acute Brain Injury in Infants: Technical Note. J Craniofac Surg 2020; 31:e707-e710. [PMID: 32604285 DOI: 10.1097/scs.0000000000006637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Decompressive craniectomy (DC) is rarely required in infants, but when performed several aspects should be considered: These youngest patients are vulnerable to blood loss and cranial reconstruction can be challenging due to skull growth and bone flap resorption. On the other hand, infants have thin and flexible bone and osteogenic potential. The authors propose a technique which makes use of these unique aspects by achieving decompression with the craniofacial method of barrel stave osteotomy, aiming to achieve adequate DC, limit perioperative risks and facilitate subsequent cranial reconstruction.
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Hanko M, Soršák J, Snopko P, Opšenák R, Zeleňák K, Kolarovszki B. Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: a 5-year experience. Eur J Trauma Emerg Surg 2020; 47:1635-1647. [PMID: 32307561 DOI: 10.1007/s00068-020-01367-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Decompressive craniectomy is an effective measure to reduce a pathologically elevated intracranial pressure. Patients' survival and life quality following this surgery have been a subject of several studies and significantly differ according to the primary diagnosis. Since this operation is often associated with a wide spectrum of possibly serious complications, we aimed to describe their incidence and possible associated risk factors. METHODS We evaluated 118 patients who underwent decompressive craniectomy at our clinic during years 2013-2017. The indications included traumatic brain injuries, ischaemic or haemorrhagic strokes and postoperative complications of planned neurosurgical procedures. Subsequently, we assessed the incidence of early postoperative complications (occurring during the first 3 postoperative weeks). The results were statistically analysed with relation to a wide selection of possible risk factors. RESULTS At least one early surgical postoperative complication occurred in 87 (73.73%) patients, the most frequent being a development of an extraaxial fluid collection in 41 (34.75%) patients. We were able to identify risk factors linked with extraaxial fluid collections, subcutaneous and extradural haematomas, postoperative seizures and meningitis. An overall need for reoperation was 13.56%. Neither the duration of the surgery nor the qualification of the operating surgeon had any effect on the complications' occurrence. CONCLUSIONS Decompressive craniectomy is associated with numerous early postoperative complications with a various degree of severity. Most cases of complications can, however, be managed in a conservative way. The risk factors linked with postoperative complications should be taken into account during the indication process in each individual patient.
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Affiliation(s)
- Martin Hanko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Jakub Soršák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Pavol Snopko
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - René Opšenák
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic
| | - Branislav Kolarovszki
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava and University Hospital in Martin, Kollárova 2, Martin, 036 59, Slovak Republic.
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Tang Z, Yang K, Zhong M, Yang R, Zhang J, Jiang Q, Liu H. Predictors of 30-Day Mortality in Traumatic Brain-Injured Patients after Primary Decompressive Craniectomy. World Neurosurg 2020; 134:e298-e305. [DOI: 10.1016/j.wneu.2019.10.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 11/28/2022]
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Decompressive Craniectomy for Patients with Traumatic Brain Injury: A Pooled Analysis of Randomized Controlled Trials. World Neurosurg 2020; 133:e135-e148. [DOI: 10.1016/j.wneu.2019.08.184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/21/2022]
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Shackelford SA, Del Junco DJ, Reade MC, Bell R, Becker T, Gurney J, McCafferty R, Marion DW. Association of time to craniectomy with survival in patients with severe combat-related brain injury. Neurosurg Focus 2019; 45:E2. [PMID: 30544314 DOI: 10.3171/2018.9.focus18404] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIn combat and austere environments, evacuation to a location with neurosurgery capability is challenging. A planning target in terms of time to neurosurgery is paramount to inform prepositioning of neurosurgical and transport resources to support a population at risk. This study sought to examine the association of wait time to craniectomy with mortality in patients with severe combat-related brain injury who received decompressive craniectomy.METHODSPatients with combat-related brain injury sustained between 2005 and 2015 who underwent craniectomy at deployed surgical facilities were identified from the Department of Defense Trauma Registry and Joint Trauma System Role 2 Registry. Eligible patients survived transport to a hospital capable of diagnosing the need for craniectomy and performing surgery. Statistical analyses included unadjusted comparisons of postoperative mortality by elapsed time from injury to start of craniectomy, and Cox proportional hazards modeling adjusting for potential confounders. Time from injury to craniectomy was divided into quintiles, and explored in Cox models as a binary variable comparing early versus delayed craniectomy with cutoffs determined by the maximum value of each quintile (quintile 1 vs 2-5, quintiles 1-2 vs 3-5, etc.). Covariates included location of the facility at which the craniectomy was performed (limited-resource role 2 facility vs neurosurgically capable role 3 facility), use of head CT scan, US military status, age, head Abbreviated Injury Scale score, Injury Severity Score, and injury year. To reduce immortal time bias, time from injury to hospital arrival was included as a covariate, entry into the survival analysis cohort was defined as hospital arrival time, and early versus delayed craniectomy was modeled as a time-dependent covariate. Follow-up for survival ended at death, hospital discharge, or hospital day 16, whichever occurred first.RESULTSOf 486 patients identified as having undergone craniectomy, 213 (44%) had complete date/time values. Unadjusted postoperative mortality was 23% for quintile 1 (n = 43, time from injury to start of craniectomy 30-152 minutes); 7% for quintile 2 (n = 42, 154-210 minutes); 7% for quintile 3 (n = 43, 212-320 minutes); 19% for quintile 4 (n = 42, 325-639 minutes); and 14% for quintile 5 (n = 43, 665-3885 minutes). In Cox models adjusted for potential confounders and immortal time bias, postoperative mortality was significantly lower when time to craniectomy was within 5.33 hours of injury (quintiles 1-3) relative to longer delays (quintiles 4-5), with an adjusted hazard ratio of 0.28, 95% CI 0.10-0.76 (p = 0.012).CONCLUSIONSPostoperative mortality was significantly lower when craniectomy was initiated within 5.33 hours of injury. Further research to optimize craniectomy timing and mitigate delays is needed. Functional outcomes should also be evaluated.
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Affiliation(s)
| | - Deborah J Del Junco
- 1Joint Trauma System, Defense Center of Excellence, San Antonio.,2Department of Epidemiology and Biostatistics, University of Texas Health Science Center, San Antonio, Texas
| | - Michael C Reade
- 3Joint Health Command, Australian Defence Force, Brisbane, Queensland, Australia
| | - Randy Bell
- 4Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Jennifer Gurney
- 1Joint Trauma System, Defense Center of Excellence, San Antonio
| | - Randall McCafferty
- 6Neurosurgery, San Antonio Military Medical Center, San Antonio, Texas; and
| | - Donald W Marion
- 7Defense and Veterans Brain Injury Center, Silver Spring, Maryland
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Vankipuram S, Sasane SV, Chandra A, Ojha BK, Singh SK, Srivastava C, Jaiswal S, Bajaj A, Jaiswal M. A Comparative Analysis Between Four-Quadrant Osteoplastic Decompressive Craniotomy versus Conventional Decompressive Craniectomy for Traumatic Brain Injury. World Neurosurg 2019; 135:e393-e404. [PMID: 31821915 DOI: 10.1016/j.wneu.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/30/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Primary decompressive craniectomy (DC) is indicated to evacuate the hematoma and reduce intracranial pressure in traumatic brain injury (TBI). However, there are a myriad of complications because of absence of the bone flap. A novel technique, four-quadrant osteoplastic decompressive craniotomy (FoQOsD) retains the bone flap while achieving adequate cerebral decompression. METHODS A single-center randomized controlled trial of 115 patients with TBI needing decompressive surgery was conducted. Of these patients, 59 underwent DC and 56 underwent FoQOsD. The primary outcome determined was functional status at 6 months using the Glasgow Outcome Scale-Extended. RESULTS No significant differences were identified in baseline characteristics between both groups. Mean Glasgow Outcome Scale-Extended score was comparable at 6 months (4.28 in DC vs. 4.38 in FoQOsD; P = 0.856). Further, 22 of 58 patients in the DC group had died (38%) compared with 25 of 55 patients in the FoQOsD group (44.6%) (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.6-2.36; P = 0.6) (1 patient lost to follow-up in each group). A favorable outcome was seen in 56.8% of patients in the DC group versus 54.4% of patients in the FoQOsD group (P = 0.74). Presence of intraventricular hemorrhage and subarachnoid hemorrhage (OR, 7.17; 95% CI, 1.364-37.7; P = 0.020), opposite side contusions (OR, 3.838; 95% CI, 1.614-9.131; P = 0.002) and anisocoria (OR, 3.235; 95% CI, 1.490-7.026; P = 0.003) preoperatively were individual factors that played a significant role in final outcome. CONCLUSIONS FoQOsD is as efficacious as conventional DC with the added benefit of avoiding a second surgery. The procedure is associated with better cosmesis and fewer complications.
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Affiliation(s)
- Siddharth Vankipuram
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India.
| | - Sumeet V Sasane
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Anil Chandra
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Bal K Ojha
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Sunil K Singh
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Chhitij Srivastava
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Somil Jaiswal
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Ankur Bajaj
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
| | - Manish Jaiswal
- Department of Neurosurgery, King George's Medical University, Chowk, Lucknow, India
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Rubiano AM, Carney N, Khan AA, Ammirati M. The Role of Decompressive Craniectomy in the Context of Severe Traumatic Brain Injury: Summary of Results and Analysis of the Confidence Level of Conclusions From Systematic Reviews and Meta-Analyses. Front Neurol 2019; 10:1063. [PMID: 31649610 PMCID: PMC6795698 DOI: 10.3389/fneur.2019.01063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/20/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction: Traumatic brain injury (TBI) is a global epidemic. The incidence of TBI in low and middle-income countries (LMICs) is three times greater than in high-income countries (HICs). Decompressive craniectomy (DC) is a surgical procedure to reduce intracranial pressure (ICP) and prevent secondary injury. Multiple comparative studies, and several randomized controlled trials (RCTs) have been conducted to investigate the influence of DC for patients with severe TBI on outcomes such as mortality, ICP, neurological outcomes, and intensive care unit (ICU) and hospital length of stay. The results of these studies are inconsistent. Systematic reviews and meta-analyses have been conducted in an effort to aggregate the data from the individual studies, and perhaps derive reliable conclusions. The purpose of this project was to conduct a review of the reviews about the effectiveness of DC to improve outcomes. Methods: We conducted a systematic search of the literature to identify reviews and meta-analyses that met our pre-determined criteria. We used the AMSTAR 2 instrument to assess the quality of each of the included reviews, and determine the level of confidence. Results: Of 973 citations from the original search, five publications were included in our review. Four of them included meta-analyses. For mortality, three reviews found a positive effect of DC compared to medical management and two found no significant difference between groups. The four reviews that measured neurological outcome found no benefit of DC. The two reviews that assessed ICP both found DC to be beneficial in reducing ICP. DC demonstrated a significant reduction in ICU length of stay in the one study that measured it, and a significant reduction in hospital length of stay in the two studies that measured it. According to the AMSTAR 2 criteria, the five reviews ranged in levels of confidence from low to critically low. Conclusion: Systematic reviews and meta-analyses are important approaches for aggregating information from multiple studies. Clinicians rely of these methods for concise interpretation of scientific literature. Standards for quality of systematic reviews and meta-analyses have been established to support the quality of the reviews being produced. In the case of DC, more attention must be paid to quality standards, in the generation of both individual studies and reviews.
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Affiliation(s)
- Andrés M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogota, Colombia.,NIHR Global Health Research Group on Neurotrauma, MEDITECH Foundation, Cali, Colombia
| | - Nancy Carney
- School of Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Ahsan A Khan
- NIHR Global Health Research Group on Neurotrauma, MEDITECH Foundation, Cali, Colombia
| | - Mario Ammirati
- Center for Biotechnology, Department of Biology, College of Science and Technology, Temple University, Philadelphia, PA, United States.,Innovative Neurotherapeutic Research Program Sbarro Health Organization, Temple University, Philadelphia, PA, United States
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46
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From decompressive craniectomy to cranioplasty and beyond-a pediatric neurosurgery perspective. Childs Nerv Syst 2019; 35:1517-1524. [PMID: 31327037 DOI: 10.1007/s00381-019-04303-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/08/2019] [Indexed: 01/05/2023]
Abstract
PURPOSE Decompressive craniectomy (DC) is an established neurosurgical emergency technique. Patient selection, optimal timing, and technical aspects related to DC and subsequent cranioplasty remain subjects of debate. For children, the overall degree of evidence is low, compared with randomized controlled trials (RCTs) in adults. METHODS Here, we present a detailed retrospective analysis of pediatric DC, covering the primary procedure and cranioplasty. Results are analyzed and discussed in the light of modern scientific evidence, and conclusions are drawn to stimulate future research. RESULTS The main indication for DC in children is traumatic brain injury (TBI). Primary and secondary DC is performed with similar frequency. Outcome appears to be better than that in adults, although long-term complications (especially bone flap resorption after autologous cranioplasty) are more common in children. Overt clinical signs of cerebral herniation prior to DC are predictors of poor outcome. CONCLUSIONS We conclude that DC is an important option in the armamentarium to treat life-threatening intracranial hypertension, but further research is warranted, preferentially in a multicenter prospective registry.
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Hutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T, Bajamal AH, Barthélemy EJ, Devi BI, Bhat D, Bulters D, Chesnut R, Citerio G, Cooper DJ, Czosnyka M, Edem I, El-Ghandour NMF, Figaji A, Fountas KN, Gallagher C, Hawryluk GWJ, Iaccarino C, Joseph M, Khan T, Laeke T, Levchenko O, Liu B, Liu W, Maas A, Manley GT, Manson P, Mazzeo AT, Menon DK, Michael DB, Muehlschlegel S, Okonkwo DO, Park KB, Rosenfeld JV, Rosseau G, Rubiano AM, Shabani HK, Stocchetti N, Timmons SD, Timofeev I, Uff C, Ullman JS, Valadka A, Waran V, Wells A, Wilson MH, Servadei F. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement. Acta Neurochir (Wien) 2019; 161:1261-1274. [PMID: 31134383 PMCID: PMC6581926 DOI: 10.1007/s00701-019-03936-y] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. METHODS The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. RESULTS The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. CONCLUSIONS In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
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Affiliation(s)
- Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK.
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Tamara Tajsic
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Amos Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Abenezer Tirsit Aklilu
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Tedy Apriawan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Abdul Hafid Bajamal
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - B Indira Devi
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya Bhat
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Diederik Bulters
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Randall Chesnut
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Idara Edem
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa and University of Thessaly, Larissa, Greece
| | - Clare Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Corrado Iaccarino
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Mathew Joseph
- Department of Neurosurgery, Christian Medical College, Vellore, India
| | - Tariq Khan
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Tsegazeab Laeke
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Oleg Levchenko
- Department of Neurosurgery, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Paul Manson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Anna T Mazzeo
- Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Daniel B Michael
- Oakland University William Beaumont School of Medicine and Michigan Head & Spine Institute, Auburn Hills, MI, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesia/Critical Care & Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Gail Rosseau
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shelly D Timmons
- Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Chris Uff
- Department of Neurosurgery, The Royal London Hospital, London, UK
- Queen Mary University of London, London, UK
| | - Jamie S Ullman
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Vicknes Waran
- Neurosurgery Division, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adam Wells
- Department of Neurosurgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Mark H Wilson
- Imperial Neurotrauma Centre, Department of Surgery and Cancer, Imperial College, London, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
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Kada AY, Bouyoucef KA. [Post traumatic brain death: epidemiology and risk factors]. Pan Afr Med J 2019; 31:29. [PMID: 30918556 PMCID: PMC6430961 DOI: 10.11604/pamj.2018.31.29.16354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 08/06/2018] [Indexed: 11/11/2022] Open
Abstract
Outcome of patients with brain death can be predicted. For this reason, several research teams attempted to identify predictors of brain death. The difficulty of proposing a coherent model lies in the choice of the proposed criteria which, in most studies, are subjective. It would be appropriate to analyze a uniform population and to identify universal criteria in order to predict with certainty brain death and to obtain a feasibility score.
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Zhou JK, Zhang QS, Chen YQ, Li M, Xie Y, Ke JJ, Lin HZ, Zhang YW. Use of Hematocrit for Short-Term Prognosis of Patients with Traumatic Brain Injury After Decompressive Craniectomy. World Neurosurg 2019; 123:e141-e146. [PMID: 30468923 DOI: 10.1016/j.wneu.2018.11.095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To discuss the effects of the hematocrit (Hct) in patients with traumatic brain injury after decompressive craniectomy (DC). METHODS Demographic data, inspection and treatment procedures, and 30-day prognosis were obtained for 158 patients with head injury who underwent unilateral DC in our hospital between January 2013 and June 2018. Uni- and multivariate logistic regression was applied to analyze independent risk factors for 30-day outcome. The quantitative analysis of postoperative Hct, ΔHct (postoperative Hct minus initial Hct), and their combination for the prognosis of patients with TBI was displayed graphically using receiver operating characteristic (ROC) curves. Multiple linear regression was used to explore factors influencing postoperative Hct and ΔHct. RESULTS Short-term mortality was 29.7%. Uni- and multivariate logistic regression analysis showed that age (odds ratio [OR], 1.064; P = 0.024), Glasgow Coma Scale score (OR, 0.711; P = 0.027), Injury Severity Score (ISS) (OR, 1.156; P = 0.047), midline shift in millimeters (OR, 1.809; P <0.001), postoperative Hct (OR, 0.743; P = 0.001), and ΔHct (OR, 1.242; P =0.048) were independent risk factors for short-term death. In ROC curves, a combination of postoperative Hct and ΔHct showed the highest sensitivity (77.5%) and highest specificity (89.4%). When using this combination to predict prognosis, we could achieve an accuracy of 94.5%. ISS (β = -0.172, P = 0.022), initial Hct (β = 0.243, P = 0.001), principal hematoma location (β = -2.628, P < 0.001), hours of operation (β = -0.884, P = 0.048), and colloid quantity (β = -0.002, P = 0.001) were independent contributing factors for ΔHct, which was similar to postoperative Hct. CONCLUSIONS A combination of postoperative Hct and ΔHct could better predict short-term survival of patients with TBI. Developing an appropriate treatment strategy to increase postoperative Hct and reduce the ΔHct may be good for the short-term prognosis of patients with TBI after DC.
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Affiliation(s)
- Jin-Kui Zhou
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Qi-Shuo Zhang
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Yu-Qiang Chen
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Mu Li
- Department of Neurosurgery, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Yang Xie
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China.
| | - Jia-Jie Ke
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Huan-Zhang Lin
- Thyroid Surgery, Shantou Central Hospital Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, Guangdong Province, China
| | - Yao-Wei Zhang
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
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50
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med 2019; 20:S1-S82. [PMID: 30829890 DOI: 10.1097/pcc.0000000000001735] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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