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Bsat S, Moussalem C, Kawtharani S, El Houshiemy MN, Halaoui A, Saba T, Najjar M, Assi H, Baajour J, El-Houcheimi I, Saad GA, Darwish H. Neurosurgical Experience of Beirut Blast in the Era of Coronavirus Disease 2019 (COVID-19) from a Tertiary Referral Center. World Neurosurg 2022; 162:e659-e663. [PMID: 35367645 PMCID: PMC8969293 DOI: 10.1016/j.wneu.2022.03.112] [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: 12/29/2021] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/03/2022]
Abstract
Background In this paper, we shed the light on Beirut’s blast that took place in the coronavirus disease 2019 (COVID-19) era. An explosion that ripped the heart of Beirut, it produced a destructive shock wave that left thousands of casualties and people homeless. This explosion, which had a mushroom-like cloud appearance similar to that of Hiroshima and Nagasaki, was described as the third-biggest explosion in human history. It was a blast that not only destroyed lives but also fell as a heavy burden on the shoulders of a country that was suffering from unprecedented economic crisis on top of the COVID-19 pandemic. Facing all this, health care providers were the first line of defense in what looked like an impossible mission. Objective We seek to share with the medical community our experience and the challenges we faced, as a neurosurgery team, during this event, particularly that we were short of basic medical equipment as well as intensive care unit beds since we were in the middle of an economic crisis and the peak of the COVID-19 pandemic. This prohibited us from delivering proper care, whether in the triage of patients or in the operating room, as well as postoperative care. Now, 1 year after this sad event, we revisit the whole situation and examine all the pitfalls that could have been avoided. Thus, we discuss the importance of initiating a disaster response, in particular the neurosurgical emergency response, to be better prepared to face future potential events. Conclusions The rate-limiting step in such disasters is definitely a well-prepared trained team with a prompt and fast response. And, since time is brain, then what saves the brain is proper timing.
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Affiliation(s)
- Shadi Bsat
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Charbel Moussalem
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sarah Kawtharani
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Nabih El Houshiemy
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Adham Halaoui
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Tatiana Saba
- NeuroICU Unit, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marwan Najjar
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hazem Assi
- Neuro-Oncology Division, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jana Baajour
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - George Abi Saad
- NeuroICU Unit, American University of Beirut Medical Center, Beirut, Lebanon
| | - Houssein Darwish
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Miller ST, Cooper CF, Elsbernd P, Kerwin J, Mejia-Alvarez R, Willis AM. Localizing Clinical Patterns of Blast Traumatic Brain Injury Through Computational Modeling and Simulation. Front Neurol 2021; 12:547655. [PMID: 34093380 PMCID: PMC8173077 DOI: 10.3389/fneur.2021.547655] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
Blast traumatic brain injury is ubiquitous in modern military conflict with significant morbidity and mortality. Yet the mechanism by which blast overpressure waves cause specific intracranial injury in humans remains unclear. Reviewing of both the clinical experience of neurointensivists and neurosurgeons who treated service members exposed to blast have revealed a pattern of injury to cerebral blood vessels, manifested as subarachnoid hemorrhage, pseudoaneurysm, and early diffuse cerebral edema. Additionally, a seminal neuropathologic case series of victims of blast traumatic brain injury (TBI) showed unique astroglial scarring patterns at the following tissue interfaces: subpial glial plate, perivascular, periventricular, and cerebral gray-white interface. The uniting feature of both the clinical and neuropathologic findings in blast TBI is the co-location of injury to material interfaces, be it solid-fluid or solid-solid interface. This motivates the hypothesis that blast TBI is an injury at the intracranial mechanical interfaces. In order to investigate the intracranial interface dynamics, we performed a novel set of computational simulations using a model human head simplified but containing models of gyri, sulci, cerebrospinal fluid (CSF), ventricles, and vasculature with high spatial resolution of the mechanical interfaces. Simulations were performed within a hybrid Eulerian—Lagrangian simulation suite (CTH coupled via Zapotec to Sierra Mechanics). Because of the large computational meshes, simulations required high performance computing resources. Twenty simulations were performed across multiple exposure scenarios—overpressures of 150, 250, and 500 kPa with 1 ms overpressure durations—for multiple blast exposures (front blast, side blast, and wall blast) across large variations in material model parameters (brain shear properties, skull elastic moduli). All simulations predict fluid cavitation within CSF (where intracerebral vasculature reside) with cavitation occurring deep and diffusely into cerebral sulci. These cavitation events are adjacent to high interface strain rates at the subpial glial plate. Larger overpressure simulations (250 and 500kPa) demonstrated intraventricular cavitation—also associated with adjacent high periventricular strain rates. Additionally, models of embedded intraparenchymal vascular structures—with diameters as small as 0.6 mm—predicted intravascular cavitation with adjacent high perivascular strain rates. The co-location of local maxima of strain rates near several of the regions that appear to be preferentially damaged in blast TBI (vascular structures, subpial glial plate, perivascular regions, and periventricular regions) suggest that intracranial interface dynamics may be important in understanding how blast overpressures leads to intracranial injury.
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Affiliation(s)
- Scott T Miller
- Computational Solid Mechanics & Structural Dynamics, Sandia National Laboratories, Albuquerque, NM, United States
| | - Candice F Cooper
- Terminal Ballistics Technology, Sandia National Laboratories, Albuquerque, NM, United States
| | - Paul Elsbernd
- Department of Neurology, Brooke Army Medical Center, Fort Sam Houston, TX, United States
| | - Joseph Kerwin
- Department of Mechanical Engineering, Michigan State University, East Lansing, MI, United States
| | - Ricardo Mejia-Alvarez
- Department of Mechanical Engineering, Michigan State University, East Lansing, MI, United States
| | - Adam M Willis
- Department of Neurology, Brooke Army Medical Center, Fort Sam Houston, TX, United States.,Department of Mechanical Engineering, Michigan State University, East Lansing, MI, United States
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Blast-Induced Traumatic Brain Injuries: Experience from the Deadliest Double Suicide Bombing Attack in Iraq. World Neurosurg 2020; 145:e192-e201. [PMID: 33045452 DOI: 10.1016/j.wneu.2020.09.167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Blast-induced traumatic brain injuries (bTBIs) are increasingly frequent in civilian settings. We present the first study of individuals with bTBI in Iraq. The study focuses on one of the deadliest suicide car bomb attacks in Iraq and uses it to show the devastating nature of bTBIs. METHODS This study was conducted at the Neurosurgery Teaching Hospital in Baghdad, Iraq. A retrospective chart analysis of patients with bTBI admitted to the Neurosurgery Teaching Hospital was performed. Measured parameters included patients' demographics, initial presentation, injury patterns, hospital course, surgical management, and outcomes. RESULTS A total of 75 patients with bTBI were included in this study, 19 of whom died in the emergency room. The remaining 56 patients were admitted to the hospital. Of those patients, 68.6% (n = 39) underwent surgery, and 30.4% were managed conservatively. A modified, tailored triaging system was implemented. All surgery was guided by the principles of damage control neurosurgery. In addition, 76.9% and 46.2% of patients underwent corticectomy and decompressive craniectomy, respectively. Dural venous sinus repair was performed in 17.9% of patients, and 30.7% of the operations entailed additional steps to control major (arterial) cerebrovascular bleeding. The net bTBI-related complication rate was 76%. The total mortality was 48%. Of survivors, 10.7% (n = 8) were discharged with a severe disability. Overall, good outcomes were achieved in 41.3% of the patients. CONCLUSIONS This study sheds light on the devastating nature of bTBIs. Neurosurgeons worldwide need to be mindful of the unique triaging, diagnostic, and management requirements of these injuries.
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Tunthanathip T, Phuenpathom N, Sae-Heng S, Oearsakul T, Sakarunchai I, Kaewborisutsakul A. Traumatic cerebrovascular injury: clinical characteristics and illustrative cases. Neurosurg Focus 2020; 47:E4. [PMID: 31675714 DOI: 10.3171/2019.8.focus19382] [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: 05/18/2019] [Accepted: 08/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic cerebrovascular injury (TCVI) is a rare and serious complication of traumatic brain injury (TBI). Various forms of TCVIs have been reported, including occlusions, arteriovenous fistulas, pseudoaneurysms, and transections. They can present at a variety of intervals after TBI and may manifest as sudden episodes, progressive symptoms, and even delayed fatal events. The purpose of this study was to analyze cases of TCVI identified at a single institution and further explore types and characteristics of these complications of TBI in order to improve recognition and treatment of these injuries. METHODS The authors performed a retrospective review of cases of TCVI identified at their institution between 2013 and 2016. A total of 5178 patients presented with TBI during this time period, and 42 of these patients qualified for a diagnosis of TCVI and had adequate medical and imaging records for analysis. Data from their cases were analyzed, and 3 illustrative cases are presented in detail. RESULTS The most common type of TCVI was arteriovenous fistula (86.4%), followed by pseudoaneurysm (11.9%), occlusion (2.4%), and transection (2.4%). The mortality rate of patients with TCVI was 7.1%. CONCLUSIONS The authors describe the clinical characteristics of patients with TCVI and provide data from a series of 42 cases. It is important to recognize TCVI in order to facilitate early diagnosis and treatment.
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Sirko A, Pilipenko G, Romanukha D, Skrypnik A. Mortality and Functional Outcome Predictors in Combat-Related Penetrating Brain Injury Treatment in a Specialty Civilian Medical Facility. Mil Med 2020; 185:e774-e780. [PMID: 32091603 DOI: 10.1093/milmed/usz431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/10/2019] [Accepted: 10/30/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The combined use of new types of weapons and new types of personal protective equipment has led to changes in the occurrence, nature, and severity of penetrating brain wounds. The availability of modern equipment, methods of treatment, and trained medical personnel in a civilian hospital, as well as advanced specialty medical care, has improved treatment outcomes. There have been a limited number of publications regarding analysis and predictors of treatment outcomes in patients with combat-related penetrating brain injury in contemporary armed conflicts. The purpose of this study was to analyze the results of surgical treatment of patients with penetrating brain injury and to identify significant outcome predictors in these patients. MATERIALS AND METHODS This was a prospective analysis of penetrating brain injury in patients who were admitted to Mechnikov Dnipropetrovsk Regional Clinical Hospital, Ukraine, from May 9, 2014, to December 31, 2017. All wounds were sustained during local armed conflict in Eastern Ukraine. The primary outcomes of interest were mortality rate at 1 month and Glasgow Outcome Scale score at 12 months after the injury. RESULTS In total, 184 patients were identified with combat-related brain injury; of those, 121 patients with penetrating brain injury were included in our study. All patients were male soldiers with a mean age of 34.1 years (standard deviation [SD], 9.1 years). Mean admission Glasgow Coma Scale score was 10 (SD, 4), and mean admission Injury Severity Score was 27.7 (SD, 7.6). Mortality within 1 month was 20.7%, and intracranial purulent-septic complications were diagnosed in 11.6% of the patients. Overall, 65.3% of the patients had favorable outcome (good recovery or moderate disability) based on Glasgow Outcome Scale score at 12 months after the injury. The following were predictors of mortality or poor functional outcome at 1 year after the injury: low Glasgow Coma Scale score on admission, gunshot wound to the head, dural venous sinuses wound, presence of intracerebral hematomas, intraventricular and subarachnoid hemorrhage accompanied by lateral or axial dislocation, and presence of intracranial purulent-septic complications. CONCLUSIONS Generally, combat-related penetrating brain injuries had satisfactory treatment outcomes. Treatment outcomes in this study were comparable to those previously reported by other authors in military populations and significantly better than outcomes of peacetime penetrating brain injury treatment.
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Affiliation(s)
- Andrii Sirko
- Neurosurgery Department, Mechnikov Dnipropetrovsk Regional Clinical Hospital, Dnipro 49005, Ukraine.,Nervous Diseases and Neurosurgery Department, Dnipropetrovsk State Medical Academy, The Ministry of Healthcare of Ukraine, Dnipro 49005, Ukraine
| | - Grigoriy Pilipenko
- Neurosurgery Department, Mechnikov Dnipropetrovsk Regional Clinical Hospital, Dnipro 49005, Ukraine
| | - Dmytro Romanukha
- Nervous Diseases and Neurosurgery Department, Dnipropetrovsk State Medical Academy, The Ministry of Healthcare of Ukraine, Dnipro 49005, Ukraine
| | - Alexander Skrypnik
- Nervous Diseases and Neurosurgery Department, Dnipropetrovsk State Medical Academy, The Ministry of Healthcare of Ukraine, Dnipro 49005, Ukraine
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Tunthanathip T, Udomwitthayaphiban S. Development and Validation of a Nomogram for Predicting the Mortality after Penetrating Traumatic Brain Injury. Bull Emerg Trauma 2019; 7:347-354. [PMID: 31857996 PMCID: PMC6911715 DOI: 10.29252/beat-070402] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Objective: To determine the factors associated with mortality in penetrating brain injury (PTBI) and proposed the nomogram predicting the risk of death. Methods: A retrospective cohort study was conducted on all patients who had sustained PTBI between 2009 and 2018. Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Prognostic factors analysis was conducted using a forest plot. Therefore, the nomogram was developed and validated. For the propose of evaluation, the nomogram’s sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Receiver Operating Characteristic (ROC) curve and the area under the receiver operating characteristic (AUC) were determined for validating the optimal cut-off point of the total scores. Results: During the study period, 62 individuals enrolled. In the univariate analysis, factors associated with the morality were normal pupils’ reactivity to light (OR 0.04, p < 0.001), hypotension (OR 9.91, p<0.001), hypoxia (OR 10.2, p=0.04), bihemispheric injuries (OR 19.0, p=0.001), multilobar injuries (OR 21.5, p< 0.001), subarachnoid hemorrhage (OR 6.9, p= 0.02), intraventricular hemorrhage (OR 26.6, p= 0.006), basal cistern effacement (OR 28.8, , p<0.001), midline shift >5 mm (OR 0.19, p<0.001) were significantly associated with death. In multivariable analysis, hypotension (OR 8.82, p=0.03), normal pupils’ reactivity to light (OR 0.07, p =0.01), midline shift >5 mm (OR 18.23, p<0.007) were significantly associated with death. The nomogram’s sensitivity, specificity, PPV, NPV, and AUC for predicting mortality (total score ≥ 100) were 80%, 92.6%, 72.7%, 95.0%, and, 0.86 respectively. Conclusions: PTBI is the fatal injury depend on both clinical and neuroimaging parameters. The nomogram is the alternative method providing prognostic parameters toward implication for clinical decision making.
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Affiliation(s)
- Thara Tunthanathip
- Division of Neurological Surgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkla, Thailand
| | - Suphak Udomwitthayaphiban
- Division of Neurological Surgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkla, Thailand
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Factors associated with surgical site infection in blast-induced traumatic brain injury. Chin Med J (Engl) 2019; 132:2514-2515. [PMID: 31592910 PMCID: PMC6831064 DOI: 10.1097/cm9.0000000000000470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Tunthanathip T, Phuenpathom N, Saehaeng S, Oearsakul T, Sakarunchai I, Kaewborisutsakul A. Traumatic cerebrovascular injury: Prevalence and risk factors. Am J Emerg Med 2019; 38:182-186. [PMID: 30737001 DOI: 10.1016/j.ajem.2019.01.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/25/2019] [Accepted: 01/30/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Traumatic cerebrovascular injury (TCVI) is uncommon in traumatic brain injury (TBI). Although TCVI is a rare condition, this complication is serious. A missed or delayed diagnosis may lead to an unexpected life-threatening hemorrhagic event or persistent neurological deficit. The object of this study was to determine the prevalence and risk factors associated with TCVI. METHODS The authors retrospectively reviewed medical records and neuroimaging studies of 5178 patients with TBI. The association of various factors was investigated using time-to-event statistical analysis. A TCVI which resulted in an occlusion, arteriovenous fistula, pseudoaneurysm or cerebral artery transection was defined as an event. RESULTS Forty-two patients developed a TCVI after injuries with an overall prevalence of 0.8%. The risk factors for an intracranial arterial injury based on univariate analysis using the Cox proportional hazard regression were penetrating injury, severe head injury, orbitofacial injury, basilar skull fracture, subdural hematoma, and cerebral contusion. In multivariable analysis, the two variables that were independently associated with TCVI were basilar skull fracture (odds ratio [OR] 22.1, 95% confidence interval [CI] 11.5-42.2) followed by orbitofacial fracture (OR 13.6, 95% CI 6.8-27.3). CONCLUSIONS Although TCVI is a rare complication of TBI, early investigation in high-risk patients may be necessary for early treatment before an unexpected fatal event occurs.
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Affiliation(s)
- Thara Tunthanathip
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Nakornchai Phuenpathom
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Sakchai Saehaeng
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Thakul Oearsakul
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Ittichai Sakarunchai
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Anukoon Kaewborisutsakul
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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