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Pisică D, Volovici V, Yue JK, van Essen TA, den Boogert HF, Vande Vyvere T, Haitsma I, Nieboer D, Markowitz AJ, Yuh EL, Steyerberg EW, Peul WC, Dirven CMF, Menon DK, Manley GT, Maas AIR, Lingsma HF. Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study. Neurosurgery 2024:00006123-990000000-01172. [PMID: 38771081 DOI: 10.1227/neu.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/05/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Guideline recommendations for surgical management of traumatic epidural hematomas (EDHs) do not directly address EDHs that co-occur with other intracranial hematomas; the relative rates of isolated vs nonisolated EDHs and guideline adherence are unknown. We describe characteristics of a contemporary cohort of patients with EDHs and identify factors influencing acute surgery. METHODS This research was conducted within the longitudinal, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury cohort study which prospectively enrolled patients with traumatic brain injury from 65 hospitals in 18 European countries from 2014 to 2017. All patients with EDH on the first scan were included. We describe clinical, imaging, management, and outcome characteristics and assess associations between site and baseline characteristics and acute EDH surgery, using regression modeling. RESULTS In 461 patients with EDH, median age was 41 years (IQR 24-56), 76% were male, and median EDH volume was 5 cm3 (IQR 2-20). Concomitant acute subdural hematomas (ASDHs) and/or intraparenchymal hemorrhages were present in 328/461 patients (71%). Acute surgery was performed in 99/461 patients (21%), including 70/86 with EDH volume ≥30 cm3 (81%). Larger EDH volumes (odds ratio [OR] 1.19 [95% CI 1.14-1.24] per cm3 below 30 cm3), smaller ASDH volumes (OR 0.93 [95% CI 0.88-0.97] per cm3), and midline shift (OR 6.63 [95% CI 1.99-22.15]) were associated with acute surgery; between-site variation was observed (median OR 2.08 [95% CI 1.01-3.48]). Six-month Glasgow Outcome Scale-Extended scores ≥5 occurred in 289/389 patients (74%); 41/389 (11%) died. CONCLUSION Isolated EDHs are relatively infrequent, and two-thirds of patients harbor concomitant ASDHs and/or intraparenchymal hemorrhages. EDHs ≥30 cm3 are generally evacuated early, adhering to Brain Trauma Foundation guidelines. For heterogeneous intracranial pathology, surgical decision-making is related to clinical status and overall lesion burden. Further research should examine the optimal surgical management of EDH with concomitant lesions in traumatic brain injury, to inform updated guidelines.
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Affiliation(s)
- Dana Pisică
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Victor Volovici
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - John K Yue
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Thomas A van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Division of Neurosurgery, Department of Surgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hugo F den Boogert
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Thijs Vande Vyvere
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Amy J Markowitz
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center and Haaglanden Medical Center, Leiden and The Hague, the Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - David K Menon
- Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
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Ali AMS, Gul W, Sen J, Hewitt SJ, Olubajo F, McMahon C. Evaluating the utility of quantitative pupillometry in a neuro-critical care setting for the monitoring of intracranial pressure: A prospective cohort study. Clin Neurol Neurosurg 2024; 239:108215. [PMID: 38447480 DOI: 10.1016/j.clineuro.2024.108215] [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: 12/17/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Assessment of the pupillary light reflex (PLR) is key in intensive care monitoring of neurosurgical patients, particularly for monitoring intracranial pressure (ICP). Quantitative pupillometry using a handheld pupillometer is a reliable method for PLR assessment. However, many variables are derived from such devices. We therefore aimed to assess the performance of these variables at monitoring ICP. METHODS Sedated patients admitted to neurocritical care in a tertiary neurosurgical centre with invasive ICP monitoring were included. Hourly measurement of ICP, subjective pupillometry (SP) using a pen torch device, and quantitative pupillometry (QP) using a handheld pupillometer were performed. RESULTS 561 paired ICP, SP and QP pupillary observations from nine patients were obtained (1122 total pupillary observations). SP and QP had a moderate concordance for pupillary size (κ=0.62). SP performed poorly at detecting pupillary size changes (sensitivity=24%). In 40 (3.6%) observations, SP failed to detect a pupillary response whereas QP did. Moderate correlations with ICP were detected for maximum constriction velocity (MCV), dilation velocity (DV), and percentage change in pupillary diameter (%C). Discriminatory ability at an ICP threshold of >22 mmHg was moderate for MCV (AUC=0.631), DV (AUC=0.616), %C (AUC=0.602), and pupillary maximum size (AUC=0.625). CONCLUSION QP is superior to SP at monitoring pupillary reactivity and changes to pupillary size. Although effect sizes were moderate to weak across assessed variables, our data indicates MCV and %C as the most sensitive variables for monitoring ICP. Further study is required to validate these findings and to establish normal range cut-offs for clinical use.
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Affiliation(s)
- Ahmad M S Ali
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.
| | - Wisha Gul
- St Helens and Knowsley NHS Foundation Trust, Prescot, UK
| | - Jon Sen
- School of Medicine, Keele University, Newcastle-under-Lyme, UK
| | - Sarah-Jane Hewitt
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Farouk Olubajo
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Catherine McMahon
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
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Amorim RL, da Silva VT, Martins HO, Brasil S, Godoy DA, Mendes MT, Gattas G, Bor-Seng-Shu E, Paiva WS. Perfusion tomography in early follow-up of acute traumatic subdural hematoma: a case series. J Clin Monit Comput 2024:10.1007/s10877-024-01133-6. [PMID: 38381360 DOI: 10.1007/s10877-024-01133-6] [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: 11/22/2023] [Accepted: 01/28/2024] [Indexed: 02/22/2024]
Abstract
Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.
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Affiliation(s)
- Robson Luís Amorim
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
- Health Sciences Faculty, Federal University of Amazonas, Manaus, Brazil
| | | | | | - Sérgio Brasil
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil.
- Division of Neurosurgery, University of São Paulo, 255. Eneas de Carvalho Aguiar Av., São Paulo, 05403-000, Brazil.
| | - Daniel Agustín Godoy
- Critical Care Department, Division Neurocritical Care, Sanatorio Pasteur, Catamarca, Argentina.
- Neurointensive Care Unit, Sanatorio Pasteur. Chacabuco 747, Catamarca, 4700, Argentina.
| | | | - Gabriel Gattas
- Institute of Radiology, University of São Paulo Medical School, São Paulo, Brazil
| | - Edson Bor-Seng-Shu
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Wellingson Silva Paiva
- LIM-62, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
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Heino I, Sajanti A, Lyne SB, Frantzén J, Girard R, Cao Y, Ritala JF, Katila AJ, Takala RS, Posti JP, Saarinen AJ, Hellström S, Laukka D, Saarenpää I, Rahi M, Tenovuo O, Rinne J, Koskimäki J. Outcome and survival of surgically treated acute subdural hematomas and postcraniotomy hematomas - A retrospective cohort study. BRAIN & SPINE 2023; 3:102714. [PMID: 38105801 PMCID: PMC10724206 DOI: 10.1016/j.bas.2023.102714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023]
Abstract
Background The morbidity and mortality of acute subdural hematoma (aSDH) remains high. Several factors have been reported to affect the outcome and survival of these patients. In this study, we explored factors potentially associated with the outcome and survival of surgically treated acute subdural hematoma (aSDH), including postcraniotomy hematomas (PCHs). Methods This retrospective cohort study was conducted in a single tertiary university hospital between 2008 and 2012 and all aSDH patients that underwent surgical intervention were included. A total of 132 cases were identified for collection of demographics, clinical, laboratory, and imaging data. Univariate and multivariable analyses were performed to assess factors associated with three-month Glasgow Outcome Scale (GOS) and survival at one- and five-year. Results In this study, PCH (n = 14, 10.6%) was not associated with a worse outcome according to the 3- month GOS (p = 0.37) or one (p = 0.34) and five-year (p = 0.37) survival. The multivariable analysis showed that the volume of initial hematoma (p = 0.009) and Abbreviated Injury Scale score (p = 0.016) were independent predictors of the three-month GOS. Glasgow Coma Scale (GCS) score (p < 0.001 and p = 0.037) and age (p = 0.048 and p = 0.003) were predictors for one and five-year survival, while use of antiplatelet drug (p = 0.030), neuroworsening (p = 0.005) and smoking (p = 0.026) were significant factors impacting one year survival. In addition, blood alcohol level on admission was a predictor for five-year survival (p = 0.025). Conclusions These elucidations underscore that, although PCHs are pertinent, a comprehensive appreciation of multifarious variables is indispensable in aSDH prognosis. These findings are observational, not causal. Expanded research endeavors are advocated to corroborate these insights.
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Affiliation(s)
- Iiro Heino
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Antti Sajanti
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Seán B. Lyne
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janek Frantzén
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, (5841 S. Maryland), Chicago, IL, 60637, USA
| | - Ying Cao
- Department of Radiation Oncology, Kansas University Medical Center, Kansas City, KS, 66160, USA
| | - Joel F. Ritala
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Ari J. Katila
- Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Riikka S.K. Takala
- Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Jussi P. Posti
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
- Neurocenter, Turku Brain Injury Center, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
- Department of Clinical Neurosciences, University of Turku, P.O. Box 52 (Kiinamyllynkatu 4-8), FI-20520, Turku, Finland
| | - Antti J. Saarinen
- Department of Paediatric Orthopaedic Surgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Santtu Hellström
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Dan Laukka
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Ilkka Saarenpää
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Melissa Rahi
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Olli Tenovuo
- Neurocenter, Turku Brain Injury Center, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
- Department of Clinical Neurosciences, University of Turku, P.O. Box 52 (Kiinamyllynkatu 4-8), FI-20520, Turku, Finland
| | - Jaakko Rinne
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Janne Koskimäki
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
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Menat S, Jacquens A, Mathon B, Bonnet B, Schotar E, Boch AL, Carpentier A, Puybasset L, Abdennour L, Degos V. Corticosteroid treatment for refractory intracranial hypertension: a rescue therapy in patients with severe traumatic brain injury with contusional lesions-a feedback. Acta Neurochir (Wien) 2023; 165:717-725. [PMID: 36808006 DOI: 10.1007/s00701-023-05507-8] [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: 12/29/2022] [Accepted: 01/21/2023] [Indexed: 02/21/2023]
Abstract
INTRODUCTION Refractory intracranial hypertension (rICH) is a severe complication among patients with severe traumatic brain injury (sTBI). Medical treatment may be insufficient, and in some cases, the only viable treatment option is decompressive hemicraniectomy. The assessment of a corticosteroid therapy against vasogenic edema secondary to severe brain injuries seems interesting to prevent this surgery in sTBI patients with rICH caused by contusional areas. METHODS This is a monocentric retrospective observational study including all consecutive sTBI patients with contusion injuries and a rICH requiring cerebrospinal fluid drainage with external ventricular drainage between November 2013 and January 2018. Patient inclusion criterium was a therapeutic index load (TIL; an indirect measure of TBI severity) > 7. Intracranial pressure (ICP) and TIL were assessed before and 48 h after corticosteroid therapy (CTC). Then, we divided the population into two groups according to the evolution of the TIL: responders and non-responders to corticosteroid therapy. RESULTS During the study period, 512 patients were hospitalized for sTBI, and among them, 44 (8.6%) with rICH were included. They received 240 mg per day [120 mg, 240 mg] of Solu-Medrol for 2 days [1; 3], 3 days after the sTBI. The average ICP in patients with rICH before the CTC bolus was 21 mmHg [19; 23]. After the CTC bolus, the ICP fell significantly to less than 15 mmHg (p < 0.0001) for at least 7 days. The TIL decreased significantly the day after the CTC bolus and until day 2. Among these 44 patients, 68% were included in the responder group (n = 30). DISCUSSION Short and systemic corticosteroid therapy in patients with refractory intracranial hypertension secondary to severe traumatic brain injury seems to be a potentially useful and efficient treatment for lowering intracranial pressure and decreasing the need for more invasive surgeries.
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Affiliation(s)
- Sophie Menat
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France
| | - Alice Jacquens
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France.
| | - Bertrand Mathon
- Department of Neurosurgery, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Baptiste Bonnet
- Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Eimad Schotar
- Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France.,Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Alexandre Carpentier
- Department of Neurosurgery, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Louis Puybasset
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France.,Department of Neuroradiology, APHP - Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France
| | - Lamine Abdennour
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France
| | - Vincent Degos
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013, Paris, France
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van Essen TA, Res L, Schoones J, de Ruiter G, Dekkers O, Maas A, Peul W, van der Gaag NA. Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute? J Neurotrauma 2023; 40:22-32. [PMID: 35699084 DOI: 10.1089/neu.2022.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.
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Affiliation(s)
- Thomas Arjan van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk Res
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Jan Schoones
- Directorate of Research Policy (Walaeus Library), and Leiden University Medical Center, Leiden, The Netherlands
| | - Godard de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Olaf Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Niels Anthony van der Gaag
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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7
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Choi DH, Jeong TS, Kim WK. Clinical Outcome of Patients Diagnosed Traumatic Intracranial Epidural Hematoma With Severe Brain Injury (Glasgow Coma Scale ≤8) Who Undergo Surgery: A Report From the Korean Neuro-Trauma Data Bank System. Korean J Neurotrauma 2022; 18:153-160. [PMID: 36381437 PMCID: PMC9634314 DOI: 10.13004/kjnt.2022.18.e62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 08/19/2023] Open
Abstract
OBJECTIVE To evaluate the clinical outcomes and prognostic factors in surgically treated patients with severe brain injury (Glasgow Coma Scale [GCS] score ≤8) diagnosed with traumatic epidural hematoma (EDH). METHODS From January 2018 to June 2021, 1,122 patients with an initial GCS score ≤8 were retrospectively enrolled in the Korean Neuro-Trauma Data Bank System. Clinical data of 79 surgically treated patients with EDH were compared between the unfavorable (scores of 1-4 on the Glasgow Outcome Scale-Extended [GOSE]) and favorable (score of 5-8 on the GOSE) outcome groups. RESULTS The overall mortality rate was 13.9%, and 60.8% of the patients had good outcomes at six months post-trauma. In the univariate analysis, increasing age (p=0.010), lower initial GCS score (p=0.001), higher Rotterdam computed tomography (CT) score (p=0.012), craniotomy rather than craniectomy (p=0.032), larger EDH volume (p=0.007), and loss of pupillary reactivity (unilateral unreactive pupil, p=0.026; bilateral unreactive pupils, p<0.001), were significantly correlated with unfavorable outcomes. Of these factors, increasing age (p=0.011) and bilateral unreactive pupils (p=0.002) were the most significant risk factors in the multivariate logistic regression analysis. The interval from admission to the brain CT scan was not correlated with the outcome; however, it was significantly longer in the unfavorable outcome group. CONCLUSION Despite severe brain injury, more than half of the patients with EDH had favorable outcomes after surgical treatment. Our findings suggest that prompt diagnosis and surgical treatment should be considered for such cases.
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Affiliation(s)
- Dae Han Choi
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Tae Seok Jeong
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- Korea Neuro-Trauma Data Bank Committee, Korean Neurotraumatology Society, Seoul, Korea
| | - Woo Kyung Kim
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - KNTDB Investigators
- Korea Neuro-Trauma Data Bank Committee, Korean Neurotraumatology Society, Seoul, Korea
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Chao M, Wang CC, Chen CPC, Chung CY, Ouyang CH, Chen CC. The Influence of Serious Extracranial Injury on In-Hospital Mortality in Children with Severe Traumatic Brain Injury. J Pers Med 2022; 12:jpm12071075. [PMID: 35887572 PMCID: PMC9323906 DOI: 10.3390/jpm12071075] [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: 06/03/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Severe traumatic brain injury (sTBI) is the leading cause of death in children. Serious extracranial injury (SEI) commonly coexists with sTBI after the high impact of trauma. Limited studies evaluate the influence of SEI on the prognosis of pediatric sTBI. We aimed to analyze SEI’s clinical characteristics and initial presentations and evaluate if SEI is predictive of higher in-hospital mortality in these sTBI children. (2) Methods: In this 11-year-observational cohort study, a total of 148 severe sTBI children were enrolled. We collected patients’ initial data in the emergency department, including gender, age, mechanism of injury, coexisting SEI, motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and intracranial Rotterdam computed tomography (CT) score of the first brain CT scan, as potential mortality predictors. (3) Results: Compared to sTBI children without SEI, children with SEI were older and more presented with initial hypotension and hypothermia; the initial lab showed more prolonged prothrombin time and a higher in-hospital mortality rate. Multivariate analysis showed that motor components of mGCS, fixed pupil reaction, prolonged prothrombin time, and higher Rotterdam CT score were independent predictors of in-hospital mortality in sTBI children. SEI was not an independent predictor of mortality. (4) Conclusions: sTBI children with SEI had significantly higher in-hospital mortality than those without. SEI was not an independent predictor of mortality in our study. Brain injury intensity and its presentations, including lower mGCS, fixed pupil reaction, higher Rotterdam CT score, and severe injury-induced systemic response, presented as initial prolonged prothrombin time, were independent predictors of in-hospital mortality in these sTBI children.
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Affiliation(s)
- Min Chao
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
| | - Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (C.-C.W.); (C.-H.O.)
| | - Carl P. C. Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
| | - Chia-Ying Chung
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
| | - Chun-Hsiang Ouyang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (C.-C.W.); (C.-H.O.)
| | - Chih-Chi Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
- Correspondence:
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Jain R, The CS, Murphy MM, Pandit AS. Surgical significance of prolonged fixed and dilated pupils in a case of non-traumatic, spontaneously regressing, acute subdural haemorrhage. BMJ Case Rep 2022; 15:e247388. [PMID: 35473704 PMCID: PMC9045004 DOI: 10.1136/bcr-2021-247388] [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] [Accepted: 04/06/2022] [Indexed: 11/04/2022] Open
Abstract
Bilaterally fixed and dilated pupils (BFDP) in traumatic acute subdural haematoma (ASDH) patients represent an ominous sign that portends irreversible brainstem injury and death. Whether patients with spontaneous ASDH and BFDP follow similar outcomes is unknown. We present a mid-60s man, found unconscious, with a Glasgow Coma Scale (GCS) of 4 following 8 days of headaches. Emergency CT imaging demonstrated a large right ASDH and the patient exhibited BFDP for >3 hours despite sedation and mannitol. Neurological improvement and spontaneously reduced SDH thickness were observed 10 hours postadmission, and he was later transferred for craniotomy and ASDH evacuation. His long-term outcomes were good: achieving independence in his activities of daily living and a GCS of 15. To the best of our knowledge, this is the first reported patient with a spontaneous, regressing ASDH and prolonged BFDP who clinically improved. This case raises important questions regarding factors used to determine prognosis and surgical viability for ASDH.
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Affiliation(s)
- Raunak Jain
- Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Crystallynn Skye The
- Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Mary M Murphy
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Anand S Pandit
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
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10
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Superiority of craniotomy over supportive care for octogenarians and nonagenarians in operable acute traumatic subdural hematoma. Clin Neurol Neurosurg 2021; 212:107069. [PMID: 34844161 DOI: 10.1016/j.clineuro.2021.107069] [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] [Received: 08/28/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Neurosurgical evacuation in elderly trauma patients is controversial. We analyzed impact of craniotomy for acute subdural hematoma on survival in octogenarians and nonagenarians. Methods The study population included all patients aged ≥ 80 years who presented with acute traumatic SDHs 09/01/15 - 01/01/20, with radiography indicating operative eligibility (i.e. MLS >5 mm and/or overall thickness >10 mm). Of 1054 TBIs aged ≥ 80 years, 104 (9.87%) were surgically indicated. Of these, 35 received craniotomy and 69 received supportive measures due to family/patient wishes or surgeon's professional decision. We analyzed these data using a Poisson regression adjusted for influence of covariates. RESULTS Of 35 craniotomies, 21 (60.00%) were deceased at 2 years of follow-up, compared to 48 (69.57%) deceased of 69 non-surgical patients. No significant demographic differences existed between these groups, other than age (craniotomy patients were younger; median age 84 vs 86; p < 0.001). In outcomes, the craniotomy cohort survived longer and in higher proportions (p = 0.028; Gehan-Breslow-Wilcoxon). When adjusting for covariates, this effect became more pronounced: craniotomy patients died at 41.1% the rate of non-surgical ones. Of all the covariates, only initial GCS significantly impacted the protective effect of craniotomy. In a logarithmic relationship, each point on initial GCS was associated with less benefit from surgery. We also found that patients with GCS< 3 were overall less likely to benefit from surgery. Our conclusions are limited by the impact of patient/surgeon choice on whether or not to operate. It is possible healthier subjects elected for craniotomies. We have attempted to correct for this by including comorbidities as covariates in our regression analyses. CONCLUSIONS Our results indicate a surgical benefit for this elderly cohort, consistent with prior findings of benefit in the setting of severe traumatic aSDH. Patients with worse neurologic impairment, i.e. low GCS, had the greatest survival benefit from surgical intervention.
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11
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Farraj Y, Buxboim A, Cohen JE, Kan-Tor Y, Glasner Hagege S, Weiss D, Goldman V, Beatus T. Measuring pupil size and light response through closed eyelids. BIOMEDICAL OPTICS EXPRESS 2021; 12:6485-6495. [PMID: 34745751 PMCID: PMC8548001 DOI: 10.1364/boe.435508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/18/2021] [Accepted: 09/01/2021] [Indexed: 06/13/2023]
Abstract
Monitoring pupillary size and light-reactivity is a key component of the neurologic assessment in comatose patients after stroke or brain trauma. Currently, pupillary evaluation is performed manually at a frequency often too low to ensure timely alert for irreversible brain damage. We present a novel method for monitoring pupillary size and reactivity through closed eyelids. Our method is based on side illuminating in near-IR through the temple and imaging through the closed eyelid. Successfully tested in a clinical trial, this technology can be implemented as an automated device for continuous pupillary monitoring, which may save staff resources and provide earlier alert to potential brain damage in comatose patients.
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Affiliation(s)
- Yousef Farraj
- Casali Center for Applied Chemistry, Institute of Chemistry, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Equally contributed
| | - Amnon Buxboim
- The Benin School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Department of Developmental and Cell Biology, The Silberman Institute of Life Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- The Alexander Grass Bioengineering Center, Faculty of Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Equally contributed
| | - Jose E. Cohen
- Department of Neurosurgery, Hadassah Hebrew University Medical Center, Jerusalem 9112001, Israel
| | - Yoav Kan-Tor
- The Benin School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Department of Developmental and Cell Biology, The Silberman Institute of Life Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- The Alexander Grass Bioengineering Center, Faculty of Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
| | - Shira Glasner Hagege
- School of Business Administration, The Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Dor Weiss
- School of Business Administration, The Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Vladimir Goldman
- Department of Orthopedic Surgery, Hadassah Hebrew University Medical Center, Jerusalem 9112001, Israel
| | - Tsevi Beatus
- The Benin School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- The Alexander Grass Bioengineering Center, Faculty of Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
- Department of Neurobiology, The Silberman Institute of Life Science, The Hebrew University of Jerusalem, Jerusalem 9190401, Israel
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12
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Kulesza B, Mazurek M, Nogalski A, Rola R. Factors with the strongest prognostic value associated with in-hospital mortality rate among patients operated for acute subdural and epidural hematoma. Eur J Trauma Emerg Surg 2020; 47:1517-1525. [PMID: 32776246 PMCID: PMC8476473 DOI: 10.1007/s00068-020-01460-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 08/05/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) still remains a serious health problem and is called a "silent epidemic". Each year in Europe 262 per 100,000 individuals suffer from TBI. The most common consequence of severe head injuries include acute subdural (SDH) and epidural hematomas (EDH), which usually require immediate surgically treatment. The aim of our study is to identify factors which have the strongest prognostic value in relation to in-hospital mortality rate among of patients undergoing surgery for EDH and SDH. PATIENTS AND METHODS Cohort included 128 patients with isolated craniocerebral injuries who underwent surgery for EDH (28 patients) and SDH (100 patients) in a single, tertiary care Department of Neurosurgery. The data were collected on admission of patients to the Emergency Department and retrospectively analyzed. The following factors were analyzed: demographic data, physiological parameters, laboratory variables, computed tomography scan characteristics and the time between trauma and surgery. Likewise, we have investigated the in-hospital mortality of patients at the time of discharge. RESULTS We found that the factors with the strongest prognostic values were: the initial GCS score, respiratory rate, glycaemia, blood saturation, systolic blood pressure, midline shift and type of hematoma. Additionally, we proved that a drop by one point in the GCS score almost doubles the risk of in-hospital death while the presence of coagulopathy increases the risk of in-hospital death almost six times. CONCLUSION Most of the factors with the strongest prognostic value are factors that the emergency team can treat prior to the hospital admission. Coagulopathy, however that has the strongest influence on in-hospital death rate can only be efficiently treated in a hospital setting.
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Affiliation(s)
- Bartłomiej Kulesza
- Chair and Department of Neurosurgery and Paediatric Neurosurgery, Medical University in Lublin, Independent Public Clinical Hospital No. 4 in Lublin, Jaczewskiego 8, 20-954, Lublin, Poland.
| | - Marek Mazurek
- Chair and Department of Neurosurgery and Paediatric Neurosurgery, Medical University in Lublin, Independent Public Clinical Hospital No. 4 in Lublin, Jaczewskiego 8, 20-954, Lublin, Poland
| | - Adam Nogalski
- Chair and Department of Trauma Surgery and Emergency Medicine, Medical University in Lublin, Independent Public Clinical Hospital No. 1 in Lublin Poland, Stanisława Sztaszica 16, 20-400, Lublin, Poland
| | - Radosław Rola
- Chair and Department of Neurosurgery and Paediatric Neurosurgery, Medical University in Lublin, Independent Public Clinical Hospital No. 4 in Lublin, Jaczewskiego 8, 20-954, Lublin, Poland
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13
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Prognosis and futility in neurosurgical emergencies: A review. Clin Neurol Neurosurg 2020; 195:105851. [PMID: 32422469 DOI: 10.1016/j.clineuro.2020.105851] [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: 04/03/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 11/22/2022]
Abstract
A patient with a life-threatening intracranial insult presents a difficult situation to the neurosurgeon. In a few short minutes the neurosurgeon must assess the patient's neurologic status, imaging, and medical condition then confer with the patient's proxy regarding treatment. This assessment ideally includes recognition of situations where aggressive care is futile and therefore such treatments should not be offered. The proxy discussion must involve surgical and nonsurgical management options and the impact of these options on survival and residual disability. Surgical decision-making is frequently difficult, even for designated proxies armed with advance directives, as these documents are usually vague with regard to acceptable functional outcomes. To complicate things further, when emergencies are off-hours, housestaff or physician extenders may need to represent the medical team in these discussions so that surgical treatment, if desired, can be arranged expeditiously. These difficulties sometimes lead to the performance of emergent surgical procedures in situations where poor outcome is certain, with deleterious effects to the patient, family, and healthcare system. It is clear then that neurosurgeons as well as their housestaff and extenders should have working knowledge of prognostic information relating to intracranial insults and familiarity with the complex ethical concept of medical futility. In this paper we review the relevant literature and our goal is to juxtapose these topics so as to provide a framework for decision making in that critical time.
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14
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Taylor BES, Narayan V, Jumah F, Al-Mufti F, Nosko M, Roychowdhury S, Nanda A, Gupta G. Ethical and medicolegal aspects in the management of neurosurgical emergencies among Jehovah's Witnesses: Clinical implications and review. Clin Neurol Neurosurg 2020; 194:105798. [PMID: 32222653 DOI: 10.1016/j.clineuro.2020.105798] [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: 10/04/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
Abstract
When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness.
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Affiliation(s)
- Blake E S Taylor
- Department of Neurosurgery, Rutgers- New Jersey Medical School, Newark, NJ, USA
| | - Vinayak Narayan
- Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Fareed Jumah
- Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Nosko
- Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sudipta Roychowdhury
- Department of Radiology, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Department of Neurology, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anil Nanda
- Department of Neurosurgery, Rutgers- New Jersey Medical School, Newark, NJ, USA; Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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Management and outcomes following emergency surgery for traumatic brain injury - A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study). Int J Surg Protoc 2020; 20:1-7. [PMID: 32211566 PMCID: PMC7082548 DOI: 10.1016/j.isjp.2020.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/09/2020] [Indexed: 12/05/2022] Open
Abstract
An estimated 27 million traumatic brain injuries (TBIs) occur worldwide every year. In certain cases, neurosurgical intervention for TBI is necessary and life-saving. The timing and quality of surgery for TBI has long been known to dramatically affect outcome. There is a paucity of data on outcomes following neurosurgery globally. GNOS will compare outcomes following emergency surgery for TBI worldwide.
Introduction Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. Methods and analysis The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. Ethics and dissemination This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.
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16
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Survival and outcome in patients with aneurysmal subarachnoid hemorrhage in Glasgow coma score 3-5. Acta Neurochir (Wien) 2020; 162:533-544. [PMID: 31980948 DOI: 10.1007/s00701-019-04190-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/19/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outcome of early, aggressive management of aneurysmal subarachnoid hemorrhage (aSAH) in patients with Hunt and Hess grade V is hitherto limited, and we therefore present our results. METHODS Retrospective study analyzing the medical data of 228 aSAH patients in Glasgow Coma Score 3-5 admitted to our hospital during the years 2002-2012. Background and treatment variables were registered. Outcome was evaluated after 3 and 12 months. RESULTS We intended to treat 176 (77.2%) patients, but only 146 went on to aneurysm repair. Of 52 patients managed conservatively, 27 had abolished cerebral circulation around arrival and 25 were deemed unsalvageable. One-year overall mortality was 65.8% and most (84.7%) of the fatalities occurred within 30 days. One-year mortality was higher in patients > 70 years. Without aneurysm repair, mortality was 100%. After 1 year, 21.9% of all patients lived independently and 4.8% lived permanently in an institution. Outcome in the 78 survivors (34.2%) was favorable in 64.1% in terms of modified Rankin Scale score 0-2, and 85.9% of survivors were able to live at home. Return to work was low for all 228 patients with 14.0% of those employed prior to the hemorrhage having returned to paid work, and respectively, 26.3% in the subgroup of survivors. CONCLUSIONS Even with aggressive, early treatment, 1-year mortality is high in comatose aSAH patients with 65.8%. A substantial portion of the survivors have a favorable outcome at 1 year (64.1%, corresponding to 21.9% of all patients admitted) and 85.9% of the survivors could live at home alone or aided.
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Ong C, Hutch M, Smirnakis S. The Effect of Ambient Light Conditions on Quantitative Pupillometry. Neurocrit Care 2020; 30:316-321. [PMID: 30218349 DOI: 10.1007/s12028-018-0607-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Automated devices collecting quantitative measurements of pupil size and reactivity are increasingly used for critically ill patients with neurological disease. However, there are limited data on the effect of ambient light conditions on pupil metrics in these patients. To address this issue, we tested the range of pupil reactivity in healthy volunteers and critically ill patients in both bright and dark conditions. METHODS We measured quantitative pupil size and reactivity in seven healthy volunteers and seven critically ill patients with the Neuroptics-200 pupillometer in both bright and dark ambient lighting conditions. Bright conditions were created by overhead LED lighting in a room with ample natural light. Dark conditions consisted of a windowless room with no overhead light source. The primary outcome was the Neurological Pupil Index (NPi), a composite metric ranging from 0 to 5 in which > 3 is considered normal. Secondary outcomes included resting and constricted pupil size, change in pupil size, constriction velocity, dilation velocity, and latency. Results were analyzed with multi-level linear regression to account for both inter- and intra-subject variability. RESULTS Fourteen subjects underwent ten pupil readings each in bright and dark conditions, yielding 280 total measurements. In healthy subjects, median NPi in bright and dark conditions was 4.2 and 4.3, respectively. In critically ill subjects, median NPi was 2.85 and 3.3, respectively. Multi-level linear regression demonstrated significant differences in pupil size, pupil size change, constriction velocity, and dilation velocity in various light levels in healthy patients, but not NPi. In the critically ill, NPi and pupil size change were significantly affected. CONCLUSION Ambient light levels impact pupil parameters in both healthy and critically ill subjects. Changes in NPi under different light conditions are small and more consistent in healthy subjects, but significantly differ in the critically ill. Practitioners should standardize lighting conditions to maximize measurement reliability.
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Affiliation(s)
- C Ong
- Boston University School of Medicine, Boston, USA. .,Brigham and Women's Hospital, Boston, USA. .,Harvard Medial School, Boston, USA.
| | - M Hutch
- Brigham and Women's Hospital, Boston, USA.,Harvard Medial School, Boston, USA
| | - S Smirnakis
- Brigham and Women's Hospital, Boston, USA.,Harvard Medial School, Boston, USA.,Jamaica Plain VA Hospital, Boston, USA
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18
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Puffer RC, Yue JK, Mesley M, Billigen JB, Sharpless J, Fetzick AL, Puccio A, Diaz-Arrastia R, Okonkwo DO. Long-term outcome in traumatic brain injury patients with midline shift: a secondary analysis of the Phase 3 COBRIT clinical trial. J Neurosurg 2019; 131:596-603. [PMID: 30074459 DOI: 10.3171/2018.2.jns173138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Following traumatic brain injury (TBI), midline shift of the brain at the level of the septum pellucidum is often caused by unilateral space-occupying lesions and is associated with increased intracranial pressure and worsened morbidity and mortality. While outcome has been studied in this population, the recovery trajectory has not been reported in a large cohort of patients with TBI. The authors sought to utilize the Citicoline Brain Injury Treatment (COBRIT) trial to analyze patient recovery over time depending on degree of midline shift at presentation. METHODS Patient data from the COBRIT trial were stratified into 4 groups of midline shift, and outcome measures were analyzed at 30, 90, and 180 days postinjury. A recovery trajectory analysis was performed identifying patients with outcome measures at all 3 time points to analyze the degree of recovery based on midline shift at presentation. RESULTS There were 892, 1169, and 895 patients with adequate outcome data at 30, 90, and 180 days, respectively. Rates of favorable outcome (Glasgow Outcome Scale-Extended [GOS-E] scores 4-8) at 6 months postinjury were 87% for patients with no midline shift, 79% for patients with 1-5 mm of shift, 64% for patients with 6-10 mm of shift, and 47% for patients with > 10 mm of shift. The mean improvement from unfavorable outcome (GOS-E scores 2 and 3) to favorable outcome (GOS-E scores 4-8) from 1 month to 6 months in all groups was 20% (range 4%-29%). The mean GOS-E score for patients in the 6- to 10-mm group crossed from unfavorable outcome (GOS-E scores 2 and 3) into favorable outcome (GOS-E scores 4-8) at 90 days, and the mean GOS-E of patients in the > 10-mm group nearly reached the threshold of favorable outcome by 180 days postinjury. CONCLUSIONS In this secondary analysis of the Phase 3 COBRIT trial, TBI patients with less than 10 mm of midline shift on admission head CT had significantly improved functional outcomes through 180 days after injury compared with those with greater than 10 mm of midline shift. Of note, nearly 50% of patients with > 10 mm of midline shift achieved a favorable outcome (GOS-E score 4-8) by 6 months postinjury.
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Affiliation(s)
- Ross C Puffer
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - John K Yue
- 2Department of Neurosurgery, UPMC, Pittsburgh; and
| | | | | | | | | | - Ava Puccio
- 2Department of Neurosurgery, UPMC, Pittsburgh; and
| | - Ramon Diaz-Arrastia
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Papangelou A, Zink EK, Chang WTW, Frattalone A, Gergen D, Gottschalk A, Geocadin RG. Automated Pupillometry and Detection of Clinical Transtentorial Brain Herniation: A Case Series. Mil Med 2019; 183:e113-e121. [PMID: 29315412 DOI: 10.1093/milmed/usx018] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/24/2017] [Indexed: 11/14/2022] Open
Abstract
Introduction Transtentorial herniation (TTH) is a life-threatening neurologic condition that typically results from expansion of supratentorial mass lesions. A change in bedside pupillary examination is central to the clinical diagnosis of TTH. Materials and. Methods To quantify the changes in the pupillary examination that precede and accompany TTH and its treatment, we evaluated 12 episodes of herniation in three patients with supratentorial mass lesions using automated pupillometry (NeurOptics, Inc., Irvine, CA). Herniation was defined clinically by the onset of fixed and dilated pupils in association with decreased levels of consciousness. Automated pupillometry was measured simultaneously with the bedside clinical examination, but the clinical team was blinded to these results and could not act on the data. Data from the pupillometer were downloaded 1-2 times per week onto a secured laptop, and data processing was facilitated by the use of Mathematica 8.0. Results Neurologic Pupil Index measurements, values generated by the pupillometer based on an algorithm that incorporates pupillary size and reactivity in a normal population, were found to be abnormal before 73% of TTHs. This abnormality occurred at a median of 7.4 h before TTH. All episodes of TTH were reversed after clinical intervention at a median of 43 min after the event. The value did not fall to 0 in 42% of clinical herniations, but it did decrease to very abnormal values of 0.5-0.8. Conclusions The potential of automated pupillometry to guide the management of severely injured neurologic patients is intriguing and warrants further study in the critical care unit and beyond. The utility of a portable device in the combat setting may allow for triage of patients with severe neurologic injury.
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Affiliation(s)
- Alexander Papangelou
- Department of Anesthesiology, Emory University Hospital, 1364 Clifton Road NE, Atlanta GA 30322
| | - Elizabeth K Zink
- The Johns Hopkins Hospital Department of Neuroscience Nursing, 600N Wolfe Street, Baltimore MD 21287
| | - Wan-Tsu W Chang
- Department of Neurology, University of Maryland Medical Systems, 22S Greene Street, G7K55, Baltimore MD 21201.,Department of Emergency Medicine, University of Maryland Medical Systems, 22S Greene Street, G7K55, Baltimore MD 21201
| | - Anthony Frattalone
- Department of Neurology, San Antonio Military Medical, Center, 3551 Roger Brooke Drive, San Antonio TX 78219.,Department of Trauma Critical Care, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio TX 78219
| | - Daniel Gergen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287
| | - Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287.,Department of Neurosurgery, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287
| | - Romergryko G Geocadin
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287.,Department of Neurosurgery, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287.,Department of Neurology, Johns Hopkins University School of Medicine, 600N Wolfe Street, Baltimore MD 21287
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20
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De Vloo P, Nijs S, Verelst S, van Loon J, Depreitere B. Prehospital and Intrahospital Temporal Intervals in Patients Requiring Emergent Trauma Craniotomy. A 6-Year Observational Study in a Level 1 Trauma Center. World Neurosurg 2018; 114:e546-e558. [PMID: 29548947 DOI: 10.1016/j.wneu.2018.03.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE According to level 2 evidence, earlier evacuation of acute subdural or epidural hematomas necessitating surgery is associated with better outcome. Hence, guidelines recommend performing these procedures immediately. Literature on the extent and causes of prehospital and intrahospital intervals in patients with trauma requiring emergent craniotomies is almost completely lacking. Studies delineating and refining the interval before thrombolytic agent administration in ischemic stroke have dramatically reduced the door-to-needle time. A similar exercise for trauma-to-decompression time might result in comparable reductions. We aim to map intervals in emergent trauma craniotomies in our level 1 trauma center, screen for associated factors, and propose possible ways to reduce these intervals. METHODS We analyzed patients who were primarily referred (1R; n = 45) and secondarily referred (after computed tomography imaging in a community hospital [2R; n = 22]) to our emergency department (ED) and underwent emergent trauma craniotomies between 2010 and 2016. RESULTS Median prehospital interval (between emergency call and arrival at the ED) was 42 minutes for 1R patients. Median intrahospital interval (between initial ED arrival and skin incision [SI]) was 140 minutes and 268 minutes for 1R and 2R patients, respectively. In 1R patients, ED-SI interval was positively correlated with Glasgow Coma Scale score (ρ=.49; P < 0.001), but not with age, time of ED arrival, or extended Glasgow Outcome Scale score at 6 months. Based on outlier analysis, we propose prehospital and intrahospital measures to improve performance. CONCLUSIONS This is the first report on emergency call-SI interval in emergent trauma craniotomy, with a median of 174 minutes and >297 minutes for 1R and 2R patients, respectively, in our center.
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Affiliation(s)
- Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
| | - Stefaan Nijs
- Department of Traumatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Sandra Verelst
- Department of Emergency Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Johannes van Loon
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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21
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Karnjanasavitree W, Phuenpathom N, Tunthanathip T. The Optimal Operative Timing of Traumatic Intracranial Acute Subdural Hematoma Correlated with Outcome. Asian J Neurosurg 2018; 13:1158-1164. [PMID: 30459885 PMCID: PMC6208231 DOI: 10.4103/ajns.ajns_199_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective Acute subdural hematoma (ASDH) has been associated with mortality in traumatic brain injury. The timing of surgical evacuation for ASDH has still been controversial. The object of this study was to determine the temporal and clinical factors associated with outcome following surgery for ASDH. Materials and Methods The study retrospectively viewed medical records and neuroimaging studies of ASDH patients who underwent surgical evacuation. Surgical outcomes were dichotomized into favorable and unfavorable outcomes, and operative times compared between the groups. Results The records of 145 ASDH patients who underwent surgery were reviewed. Almost two-thirds of the patients were admitted for surgical evacuation, of whom 71% underwent a decompressive operation. The temporal variables were as follows: mean time from scene of accident to emergency department (ED) was 70 (Standard deviation [SD] 256.0) min, mean time from ED to obtaining CT of the brain was 45.6 (SD 38.9) min, mean time from brain computed tomographic to operating room arrival was 68.6 (SD 50.0) min, and mean time from ED arrival to skin incision was 160.1 (SD 88.1) min. The mean time from ED arrival to skin incision was significantly shorter in the unfavorable outcome group. Because of this reverse association between time from ED to surgery, multivariate analysis was applied to adjust the timing factors with other clinical factors, and the results indicated that temporal factors were not associated with functional outcome, as features such as increased intracranial pressure due to obliterated basal cistern and brain herniation were significantly associated with functional outcome. Conclusions The optimal times for surgical evacuation of ASDH are challenging to estimate because compressed brainstem signs are more important than time factors. ASDH patients with compressed brainstem should have surgery as soon as possible.
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Affiliation(s)
- Worawach Karnjanasavitree
- Department of Surgery, Neurosurgery Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Nakornchai Phuenpathom
- Department of Surgery, Neurosurgery Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thara Tunthanathip
- Department of Surgery, Neurosurgery Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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22
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Alliez JR, Kaya JM, Leone M. Ematomi intracranici post-traumatici in fase acuta. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)86804-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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23
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Chieregato A, Venditto A, Russo E, Martino C, Bini G. Aggressive medical management of acute traumatic subdural hematomas before emergency craniotomy in patients presenting with bilateral unreactive pupils. A cohort study. Acta Neurochir (Wien) 2017; 159:1553-1559. [PMID: 28435989 DOI: 10.1007/s00701-017-3190-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 04/13/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The outcome of patients with severe traumatic brain injury (TBI) and acute traumatic subdural hematoma (aSDH) admitted to the emergency room with bilaterally dilated, unreactive pupils (bilateral mydriasis) is notoriously poor. METHODS Of 2074 TBI patients consecutively admitted to our facility between 1997 and 2012, 115 had a first CT scan with aSDH, unreactive bilateral mydriasis, and a Glasgow Coma Score of 3 or 4. Sixty-two patients were unoperated and died within hours or a few days. The remaining 53 patients (2.5% of the 2074 consecutive patients) were scheduled for emergent evacuation of the aSDH. We compared three different dosages of mannitol to landmark different comprehensive levels of treatment: (1) a "basic" level of treatment characterized by a single conventional dose (18 to 36 g), (2) "reinforced" treatment landmarked by a single high dose (54 to 72 g), and (3) "aggressive" treatment landmarked by a single high dose (90 to 106 g). Doses above 36 g were administered intravenously over a period of 5 min. RESULTS Of the 53 selected patients, 7 were aggressively managed (13.2%) and 24 (45.3%) received reinforced treatment. Rates of hyperventilation and barbiturate bolus administration were appropriately associated with increasing doses of mannitol. After adjustment for age, aggressive management was significantly associated with a lower risk of death and persistent vegetative state [adjusted OR 0.016 (95% 0.001-0.405)]. Patients surviving after aggressive management suffered more severe disability at 1 year. CONCLUSION The study shows an association between reduced mortality and persistent vegetative state, albeit at the cost of increased long-term severe disability in survivors, and aggressive medical preoperative management of mydriatic patients with aSDH following TBI.
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Affiliation(s)
- Arturo Chieregato
- Neurorianimazione, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Alessandra Venditto
- Ospedale "M Bufalini", Anestesia e Rianimazione, Area Vasta Romagna, Cesena, Italy
| | - Emanuele Russo
- Ospedale "M Bufalini", Anestesia e Rianimazione, Area Vasta Romagna, Cesena, Italy
| | - Costanza Martino
- Ospedale "M Bufalini", Anestesia e Rianimazione, Area Vasta Romagna, Cesena, Italy
| | - Giovanni Bini
- Ospedale "M Bufalini", Anestesia e Rianimazione, Area Vasta Romagna, Cesena, Italy
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24
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Kim C, Park JM, Kong T, Lee S, Seo KW, Choi Y, Song YS, Moon J. Double-Injected Human Stem Cells Enhance Rehabilitation in TBI Mice Via Modulation of Survival and Inflammation. Mol Neurobiol 2017; 55:4870-4884. [PMID: 28736792 PMCID: PMC5948256 DOI: 10.1007/s12035-017-0683-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 07/07/2017] [Indexed: 12/22/2022]
Abstract
Traumatic brain injury (TBI), a complicated form of brain damage, is a major cause of mortality in adults. Following mechanical and structural primary insults, a battery of secondary insults, including neurotransmitter-mediated cytotoxicity, dysregulation of calcium and macromolecule homeostasis, and increased oxidative stress, exacerbate brain injury and functional deficits. Although stem cell therapy is considered to be an alternative treatment for brain injuries, such as TBI and stroke, many obstacles remain. In particular, the time window for TBI treatment with either drugs or stem cells and their efficacy is still vague. Human placenta-derived mesenchymal stem cells (hpMSCs) have received extensive attention in stem cell therapy because they can be acquired in large numbers without ethical issues and because of their immune-modulating capacity and effectiveness in several diseases, such as Alzheimer’s disease and stroke. Here, we tested the feasibility of hpMSCs for TBI treatment with an animal model and attempted to identify appropriate time points for cell treatments. Double injections at 4 and 24 h post-injury significantly reduced the infarct size and suppressed astrocyte and microglial activation around the injury. With reduced damage, double-injected mice showed enhanced anti-inflammatory- and TNF-α receptor 2 (TNFR2)-associated survival signals and suppressed pro-inflammatory and oxidative responses. In addition, double-treated TBI mice displayed restored sensory motor functions and reduced neurotoxic Aβ42 plaque formation around the damaged areas. In this study, we showed the extended therapeutic potentials of hpMSCs and concluded that treatment within an appropriate time window is critical for TBI recovery.
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Affiliation(s)
- Chul Kim
- General Research Institute, CHA general Hospital, Seoul, South Korea
| | - Ji-Min Park
- Department of Biotechnology, College of Life Science, CHA University, Pangyo-ro 335 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Seoul, South Korea.,General Research Institute, CHA general Hospital, Seoul, South Korea
| | - TaeHo Kong
- Department of Biotechnology, College of Life Science, CHA University, Pangyo-ro 335 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Seoul, South Korea.,General Research Institute, CHA general Hospital, Seoul, South Korea
| | - Seungmin Lee
- General Research Institute, CHA general Hospital, Seoul, South Korea
| | - Ki-Weon Seo
- General Research Institute, CHA general Hospital, Seoul, South Korea.,SK Chemicals, Eco-Hub, 332 Pangyo-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13493, South Korea
| | - Yuri Choi
- Department of Biotechnology, College of Life Science, CHA University, Pangyo-ro 335 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Seoul, South Korea
| | - Young Sook Song
- General Research Institute, CHA general Hospital, Seoul, South Korea
| | - Jisook Moon
- Department of Biotechnology, College of Life Science, CHA University, Pangyo-ro 335 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Seoul, South Korea. .,General Research Institute, CHA general Hospital, Seoul, South Korea.
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25
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Shibahashi K, Sugiyama K, Kashiura M, Okura Y, Hoda H, Hamabe Y. Emergency Trepanation as an Initial Treatment for Acute Subdural Hemorrhage: A Multicenter Retrospective Cohort Study. World Neurosurg 2017; 106:185-192. [PMID: 28669875 DOI: 10.1016/j.wneu.2017.06.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/21/2017] [Accepted: 06/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Rapid decompression with trepanation and drainage in an emergency room has been proposed as a potentially effective initial intervention for early-stage acute subdural hemorrhage; however, the actual safety and efficacy of the procedure remain unclear. The aim of this study was to evaluate the feasibility of emergency trepanation as an initial treatment for acute subdural hemorrhage. METHODS We investigated patients with thick subdural hemorrhages who had undergone craniotomy between 2004 and 2015 in Japan using a nationwide trauma registry (the Japan Trauma Data Bank). The endpoint was survival at discharge. We compared patients who underwent trepanation in an emergency room with those who did not undergo trepanation, and adjusted for potential confounders using a multivariate logistic regression model. RESULTS During the study period, 236,698 patients were registered in the Japan Trauma Data Bank. Of the 1391 patients who were eligible for analysis, 305 had undergone trepanation in an emergency room. The survival rate was 37.7% in patients who had undergone emergency trepanation and 59.3% in those who had not. Performing emergency trepanation was significantly associated with decreased survival even after adjusting for possible confounders (adjusted odds ratio, 0.55; 95% confidence interval, 0.40-0.76; P < 0.001). CONCLUSIONS Our results indicate that performing trepanation in an emergency room is associated with a decreased survival rate.
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Affiliation(s)
- Keita Shibahashi
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan.
| | - Kazuhiro Sugiyama
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Masahiro Kashiura
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Yoshihiro Okura
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Hidenori Hoda
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Yuichi Hamabe
- Department of Emergency and Intensive Care Center, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
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26
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Hamed M, Schuss P, Daher FH, Borger V, Güresir Á, Vatter H, Güresir E. Acute Traumatic Subdural Hematoma: Surgical Management in the Presence of Cerebral Herniation–A Single-Center Series and Multivariate Analysis. World Neurosurg 2016; 94:501-506. [DOI: 10.1016/j.wneu.2016.07.061] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 07/15/2016] [Accepted: 07/16/2016] [Indexed: 10/21/2022]
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27
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Potapov AA, Krylov VV, Gavrilov AG, Kravchuk AD, Likhterman LB, Petrikov SS, Talypov AE, Zakharova NE, Solodov AA. [Guidelines for the management of severe traumatic brain injury. Part 3. Surgical management of severe traumatic brain injury (Options)]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016; 80:93-101. [PMID: 27070263 DOI: 10.17116/neiro201680293-101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Traumatic brain injury (TBI) is one of the main causes of mortality and severe disability in young and middle age patients. Patients with severe TBI, who are in coma, are of particular concern. Adequate diagnosis of primary brain injuries and timely prevention and treatment of secondary injury mechanisms markedly affect the possibility of reducing mortality and severe disability. The present guidelines are based on the authors' experience in developing international and national recommendations for the diagnosis and treatment of mild TBI, penetrating gunshot wounds of the skull and brain, severe TBI, and severe consequences of brain injury, including a vegetative state. In addition, we used the materials of international and national guidelines for the diagnosis, intensive care, and surgical treatment of severe TBI, which were published in recent years. The proposed recommendations for surgical treatment of severe TBI in adults are addressed primarily to neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and intensivists who are routinely involved in treating these patients.
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Affiliation(s)
- A A Potapov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - V V Krylov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - A G Gavrilov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A D Kravchuk
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - S S Petrikov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | - A E Talypov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
| | | | - A A Solodov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow, Russia
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28
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Huang KT, Abd-El-Barr MM, Dunn IF. Skull Fractures and Structural Brain Injuries. HEAD AND NECK INJURIES IN YOUNG ATHLETES 2016:85-103. [DOI: 10.1007/978-3-319-23549-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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29
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Abstract
OBJECTIVE The Brain Trauma Foundation recommendation regarding the timing of surgical evacuation of epidural hematomas and subdural hematomas is to perform the procedure as soon as possible. Indeed, faster evacuation is associated with better outcome. However, to the authors' knowledge, no study has looked at where delays in intrahospital care occurred for patients suffering from traumatic intracranial mass lesions. The goals of this study were as follows: 1) to characterize the performance of a Level 1 trauma center in terms of delays for emergency trauma craniotomies, 2) to review step by step where delays occurred in patient care, and 3) to propose ways to improve performance. METHODS A retrospective review was conducted covering a 5-year period of all emergency trauma craniotomies. Demographic data, injury severity, neurological status, and functional outcome data were collected. The time elapsed between emergency department (ED) arrival and CT imaging, between CT imaging and arrival at the operating room (OR), between ED arrival and OR arrival, between OR arrival and skin incision, and between ED arrival and skin incision were calculated. Patients were also subcategorized as either having immediate life-threatening emergencies (E0) or life-threatening emergencies (E1). The operative technique was also reviewed (standard craniotomy opening vs immediate bur hole decompression followed by craniotomy). RESULTS The study included 166 patients. Of these, 58 (35%) were classified into the E0 group and 108 (64.2%) into the E1 group. The median ED-to-CT delay was 54 minutes with no significant difference between the E0 and the E1 groups. The median CT-to-OR time delay was 57 minutes. The median delay for the E0 group was 39 minutes and that for the E1 group was 70 minutes (p = 0.002). The median delay from ED to OR arrival for patients with a CT scanning done at an outside hospital was 75 minutes. The median delay from ED to OR arrival was 85 minutes for the E0 group and 127 minutes for the E1 group (p < 0.0001). The median delay from OR arrival to skin incision was 35 minutes (E0: median 27 minutes; E1: median 39 minutes; p < 0.0001). The median total time elapsed between ED arrival and skin incision was 150 minutes (E0: median 131 minutes; E1: median 180 minutes). Overall, only 17% of patients underwent immediate bur hole decompression, but the proportion climbed to 41% in the E0 group. A lower Glasgow Coma Scale score was associated with a shorter delay (p = 0.0004). CONCLUSIONS A long delay until surgery still exists for patients requiring urgent mass lesion evacuation. Many factors contribute to this delay, including performing imaging and transfer to and preparation in the OR. Strategies can be implemented to reduce delays and improve the delivery of care.
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Affiliation(s)
- Judith Marcoux
- Department of Neurology and Neurosurgery, McGill University; and,Departments of 2 Neurosurgery and
| | - David Bracco
- Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada
| | - Rajeet S Saluja
- Department of Neurology and Neurosurgery, McGill University; and,Departments of 2 Neurosurgery and
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30
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Mao X, Miao G, Hao S, Tao X, Hou Z, Li H, Tian R, Zhang H, Lu T, Ma J, Zhang X, Cheng H, Liu B. Decompressive craniectomy for severe traumatic brain injury patients with fixed dilated pupils. Ther Clin Risk Manag 2015; 11:1627-33. [PMID: 26543370 PMCID: PMC4622445 DOI: 10.2147/tcrm.s89820] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The outcome of decompressive craniectomy (DC) for severe traumatic brain injury (sTBI) patients with fixed dilated pupils (FDPs) is not clear. The objective of this study was to validate the outcome of DC in sTBI patients with FDPs. PATIENTS We retrospectively collected data from 207 sTBI patients with FDPs during the time period of May 4, 2003-October 22, 2013: DC group (n=166) and conservative care (CC) group (n=41). MEASUREMENTS Outcomes that were used as indicators in this study were mortality and favorable outcome. The analysis was based on the Glasgow Outcome Scale recorded at 6 months after trauma. RESULTS A total of 49.28% patients died (39.76% [DC group] vs 87.80% [CC group]). The mean increased intracranial pressure values after admission before operation were 36.20±7.55 mmHg in the DC group and 35.59±8.18 mmHg in the CC group. After performing DC, the mean ICP value was 14.38±2.60 mmHg. Approximately, 34.34% sTBI patients with FDPs in the DC group gained favorable scores and none of the patients in the CC group gained favorable scores. CONCLUSION We found that DC plays a therapeutic role in sTBI patients with FDPs, and it is particularly important to reduce intracranial pressure as soon as possible after trauma. For the patients undergoing DC, favorable outcome and low mortality could be achieved.
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Affiliation(s)
- Xiang Mao
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Guozhuan Miao
- Department of Neurotrauma, General Hospital of Armed Police Forces, Capital Medical University, Beijing, People's Republic of China
| | - Shuyu Hao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Xiaogang Tao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Zonggang Hou
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Huan Li
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Runfa Tian
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Hao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China ; Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China ; Department of Neurotrauma, General Hospital of Armed Police Forces, Capital Medical University, Beijing, People's Republic of China
| | - Te Lu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Jun Ma
- Imaging Center of Neuroscience, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaodong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Hongwei Cheng
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; Department of Neurotrauma, General Hospital of Armed Police Forces, Capital Medical University, Beijing, People's Republic of China
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Olson DM, Stutzman S, Saju C, Wilson M, Zhao W, Aiyagari V. Interrater Reliability of Pupillary Assessments. Neurocrit Care 2015; 24:251-7. [DOI: 10.1007/s12028-015-0182-1] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Mojumder DK, Patel S, Nugent K, Detoledo J, Kim J, Dar N, Wilms H. Pupil to limbus ratio: Introducing a simple objective measure using two-box method for measuring early anisocoria and progress of pupillary change in the ICU. J Neurosci Rural Pract 2015; 6:208-15. [PMID: 25883482 PMCID: PMC4387813 DOI: 10.4103/0976-3147.153229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Measurement of static pupillary size in the ICU is of importance in cases of acutely expanding intracranial mass lesions. The inaccuracies with subjective assessment of pupillary size by medical personnel preclude its use in emergent neurological situations. Objective: To determine if the ratio of pupil to limbus diameter (PLD ratio) measured by a two-box method is a reliable measure of pupil size for detecting early anisocoria and measuring pupillary changes. Materials and Methods: The PLD ratio was defined as the ratio of the pupillary diameter measured at a para-horizontal axial plane with the limbus diameter measured at the same or parallel axial plane. A two-box method was used to estimate the diameters of imaged pupils. Eyes were imaged using an iPhone 4S cellphone camera. Background illumination was measured and kept constant. The pupils of a 78-year-old woman, who presented with a large intra-axial parenchymal hemorrhage, were imaged. The patient had left pupillary miosis in dark but not in bright light. After presenting this case along with the images of the pupillary examination, a group of 21 medical staff were asked several questions on the pupillary examination. Reliability of PLD ratio were assessed via standard error of mean (S.E.M) of PLD ratios for 3 different subjects each imaged under constant illumination and fixation but from different angles to the optical axis. Results: Analysis of questionnaire data together with PLD ratios revealed that ~ 14% and 10% of participants could estimate the pupillary size in darkness and bright light respectively but none were simultaneously accurate indicating that subjective assessment of pupillary size was unreliable. The approach towards a systematic pupillary examination was inconsistent among the participants. The PLD ratio was found to be a reliable measure of pupillary size with standard error of mean below 0.1 mm for the three subjects tested. Conclusion: Static pupillary sizes can be objectively and consistently evaluated using PLD ratios using a two-box method. PLD ratios are resistant, within limits, to changes in imaging angle or choice of para-horizontal axes for measurement.
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Affiliation(s)
- Deb Kumar Mojumder
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Saumil Patel
- Department of Neuroscience, Baylor College of Medicine, Houston, Texas, USA
| | - Kenneth Nugent
- Department of Internal Medicine, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - John Detoledo
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Jongyeol Kim
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Nabeel Dar
- Department of Radiology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Henrik Wilms
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. Emerg Med J 2014; 32:654-9. [DOI: 10.1136/emermed-2014-204260] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 10/06/2014] [Indexed: 01/23/2023]
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Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation: influence of hematoma localization on outcome. Neurosurg Rev 2014; 37:653-9. [DOI: 10.1007/s10143-014-0560-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 04/03/2014] [Accepted: 05/18/2014] [Indexed: 11/25/2022]
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Traumi cranioencefalici. Neurologia 2014. [DOI: 10.1016/s1634-7072(14)67225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
OPINION STATEMENT Clinical presentation, neurologic condition, and imaging findings are the key components in establishing a treatment plan for acute SDH. Location and size of the SDH and presence of midline shift can rapidly be determined by computed tomography of the head. Immediate laboratory work up must include PT, PTT, INR, and platelet count. Presence of a coagulopathy or bleeding diathesis requires immediate reversal and treatment with the appropriate agent(s), in order to lessen the risk of hematoma expansion. Reversal protocols used are similar to those for intracerebral hemorrhage, with institutional variations. Immediate neurosurgical evaluation is sought in order to determine whether the SDH warrants surgical evacuation. Urgent or emergent surgical evacuation of a SDH is largely influenced by neurologic examination, imaging characteristics, and presence of mass effect or elevated intracranial pressure. Generally, evacuation of an acute SDH is recommended if the clot thickness exceeds 10 mm or the midline shift is greater than 5 mm, regardless of the neurologic condition. In patients with patients with an acute SDH with clot thickness <10 mm and midline shift <5 mm, specific considerations of neurologic findings and clinical circumstances will be of importance. In addition, consideration will be given as to whether an individual patient is likely to benefit from surgery. For an acute SDH, evacuation by craniotomy or craniectomy is preferred over burr holes based on available data. Postoperative care includes monitoring of resolution of pneumocephalus, mobilization and drain removal, and monitoring for signs of SDH reaccumulation. Medical considerations include seizure prophylaxis and management as well as management and resumption of antithrombotic and anticoagulant medication.
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Affiliation(s)
- Carter Gerard
- Department of Neurosurgery, Rush University Medical Center, 1725 West Harrison Street, POB, Chicago, IL, 60612, USA,
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Mihara Y, Dohi K, Nakamura S, Miyake Y, Aruga T. Novel method for emergency craniostomy for rapid control and monitoring of the intracranial pressure in severe acute subdural hematoma. Neurol Med Chir (Tokyo) 2013; 50:1039-44. [PMID: 21123995 DOI: 10.2176/nmc.50.1039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acute subdural hematoma (ASDH) is a critical condition following the onset of traumatic brain injury, and it is essential to immediately reduce elevated intracranial pressure (ICP). Single burr hole surgery/twist drill craniostomy is commonly performed in patients with ASDH as an emergency surgical intervention, usually preceding decompressive craniotomy. A novel method using a cerebrospinal fluid (CSF) drainage catheter kit for rapid drainage of ASDH is described. Percutaneous twist drill craniostomy using a CAMINO(®) micro ventricular bolt pressure-temperature monitoring kit was performed in the emergency room in 12 patients with severe ASDH. The kit contained a closed-system CSF drainage and pressure-temperature monitoring catheter, which allowed aspiration of the hematoma and monitoring of the ICP. The tip of the catheter was inserted into the hematoma from the forehead. The mean initial ICP was 61 mmHg, with a range of 31 to 120 mmHg. The liquid hematoma was aspirated, and the ICP was temporarily controlled to the normal range. Pupil dilation recovered immediately after aspiration of the hematoma in 3 patients. No complications occurred either during or after the operation. This new method for craniostomy is easy, safe, and effective to monitor and rapidly control ICP in the emergency room. This technique also offers the possibility of evaluating the patient's prognosis and determining indications for further decompressive craniectomy by the continuation of ICP control under ICP monitoring and evaluation of the reversibility of pupillary findings in ASDH patients.
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Affiliation(s)
- Yuko Mihara
- Department of Emergency and Critical Care Medicine, Showa University School of Medicine, Tokyo, Japan
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Martínez-Ricarte F, Castro A, Poca M, Sahuquillo J, Expósito L, Arribas M, Aparicio J. Infrared pupillometry. Basic principles and their application in the non-invasive monitoring of neurocritical patients. NEUROLOGÍA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.nrleng.2010.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Kalanithi P, Schubert RD, Lad SP, Harris OA, Boakye M. Hospital costs, incidence, and inhospital mortality rates of traumatic subdural hematoma in the United States. J Neurosurg 2011; 115:1013-8. [DOI: 10.3171/2011.6.jns101989] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
This study provides the first US national data regarding frequency, cost, and mortality rate of traumatic subdural hematoma (SDH), and identifies demographic factors affecting morbidity and death in patients with traumatic SDH undergoing surgical drainage.
Methods
A retrospective analysis was conducted by querying the Nationwide Inpatient Sample, the largest all-payer database of nonfederal community hospitals. All cases of traumatic SDH were identified using ICD-9 codes. The study consisted of 2 parts: 1) trends data, which were abstracted from the years 1993–2006, and 2) univariate analysis and multivariate logistic regression of demographic variables on inhospital complications and deaths for the years 1993–2002.
Results
Admissions for traumatic SDH increased 154% from 17,328 in 1993 to 43,996 in 2006. Inhospital deaths decreased from 16.4% to 11.6% for traumatic SDH. Average costs increased 67% to $47,315 per admission. For the multivariate regression analysis, between 1993 and 2002, 67,864 patients with traumatic SDH underwent operative treatment. The inhospital mortality rate was 14.9% for traumatic SDH drainage, with an 18% inhospital complication rate. Factors affecting inhospital deaths included presence of coma (OR = 2.45) and more than 2 comorbidities (OR = 1.60). Increased age did not worsen the inhospital mortality rate.
Conclusions
Nationally, frequency and cost of traumatic SDH cases are increasing rapidly.
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Affiliation(s)
- Paul Kalanithi
- 1Department of Neurosurgery, Stanford University Hospitals and Clinics, and Outcomes Research Center, VA Palo Alto Health Care System, Palo Alto; and
| | | | - Shivanand P. Lad
- 1Department of Neurosurgery, Stanford University Hospitals and Clinics, and Outcomes Research Center, VA Palo Alto Health Care System, Palo Alto; and
| | - Odette A. Harris
- 1Department of Neurosurgery, Stanford University Hospitals and Clinics, and Outcomes Research Center, VA Palo Alto Health Care System, Palo Alto; and
| | - Maxwell Boakye
- 1Department of Neurosurgery, Stanford University Hospitals and Clinics, and Outcomes Research Center, VA Palo Alto Health Care System, Palo Alto; and
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Ley EJ, Clond MA, Hussain ON, Srour M, Mirocha J, Bukur M, Margulies DR, Salim A. Mortality by Decade in Trauma Patients with Glasgow Coma Scale 3. Am Surg 2011. [DOI: 10.1177/000313481107701015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to assess how increasing age affects mortality in trauma patients with Glasgow Coma Scale (GCS) 3. The Los Angeles County Trauma System Database was queried for all patients aged 20 to 99 years admitted with GCS 3. Mortality was 41.8 per cent for the 3306 GCS 3 patients. Mortality in the youngest patients reviewed, those in the third decade, was 43.5 per cent. After logistic regression analysis, patients in the third decade had similar mortality rates to patients in the sixth (adjusted OR, 0.88; CI, 0.68 to 1.14; P = 0.33) and seventh decades (adjusted OR, 0.96; CI, 0.70 to 1.31; P = 0.79). A significantly lower mortality rate, however, was noted in the fifth decade (adjusted OR, 0.76; CI, 0.61 to 0.95; P = 0.02). Conversely, significantly higher mortality rates were noted in the eighth (adjusted OR, 1.93; CI, 1.38 to 2.71; P = 0.0001) and combined ninth/tenth decades (adjusted OR, 2.47; CI, 1.71 to 3.57; P < 0.0001). Given the high survival in trauma patients with GCS 3 as well as continued improvement in survival compared with historical controls, aggressive care is indicated for patients who present to the emergency department with GCS 3.
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Affiliation(s)
- Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Morgan A. Clond
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Omar N. Hussain
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marissa Srour
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marko Bukur
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dan R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ali Salim
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Predictors of functional recovery in African patients with traumatic intracranial hematomas. World Neurosurg 2011; 75:586-91. [PMID: 21704911 DOI: 10.1016/j.wneu.2010.05.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 05/17/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND Head injury is a critical public health problem responsible for up to 50% of fatalities among trauma patients and for a large component of continuing care among survivors. Intracranial hematomas are among the most common clinical entities encountered by any neurosurgical service and have a very high mortality rate and extremely poor prognosis among traumatic brain injuries. OBJECTIVE The purpose of this study was to investigate reliable factors influencing the functional outcome of the patients with traumatic intracranial hematomas (ICHs). METHODS A retrospective analysis was conducted of consecutive patients presenting at the Kenyatta National Hospital between January 2000 and December 2009. Following ethical approval, the records of patients admitted to the neurosurgical unit and diagnosed with traumatic ICH were retrieved and reviewed. The outcome measure was the Glasgow Outcome Scale (GOS) score at discharge. Data were collected in preformed questionnaires, and the coding and analysis were carried out using SPSS, version 11.5. RESULTS Of the 608 patients diagnosed with intracranial hematomas during the study period, there was a clear male predominance, with 89.3% male and 10.7% female patients. Majority of the patients (49%) were aged between 26 and 45 years, whereas 5.6% and 9.4% were younger than age 13 years and older than age 61 years, respectively. The most common cause of injury was assault (48%). Good functional recovery was achieved by 280 (46.1%) of the patients in our series, whereas moderate and severe disability accounted for 27% and 6.9%, respectively. Males were more likely to have functional recovery (46.4%) than were females (43.1%), though this finding was not statistically significant (P = 0.069). The proportion of patients who achieved functional recovery seemed to decrease with increasing age. Patients who were involved in motor vehicle accidents were less likely to have functional recovery (33.7%, P = 0.003) than those who fell (53.6%). There was a statistically significant difference in the proportion of patients who achieved functional recovery, with 65.2% of those who had mild head injury as compared to 46% and 15.1% (P ≤ 0.001) for those with moderate and severe head injury, respectively. Patients who had surgical intervention were more likely to achieve functional outcome (51.2%) as compared to 31.7% in those managed conservatively. Furthermore, the time elapsed from initial trauma to surgery significantly influenced outcome. The type of surgery done was not found to significantly influence patient outcome (P = 0.095). CONCLUSION An increased risk of poor outcome occurs in patients who are older than age 61 years, have lower preoperative GCS scores, pupillary abnormalities, and a long interval between trauma and decompression. The findings would help clinicians determine management criteria and improve survival.
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Chen JW, Gombart ZJ, Rogers S, Gardiner SK, Cecil S, Bullock RM. Pupillary reactivity as an early indicator of increased intracranial pressure: The introduction of the Neurological Pupil index. Surg Neurol Int 2011; 2:82. [PMID: 21748035 PMCID: PMC3130361 DOI: 10.4103/2152-7806.82248] [Citation(s) in RCA: 205] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 05/20/2011] [Indexed: 02/06/2023] Open
Abstract
Background This paper introduces the 7/5/2011al Pupil index (NPi), a sensitive measure of pupil reactivity and an early indicator of increasing intracranial pressure (ICP). This may occur in patients with severe traumatic brain injury (TBI), aneurysmal subarachnoid hemorrhage, or intracerebral hemorrhage (ICH). Methods 134 patients (mean age 46 years, range 18–87 years, 54 women and 80 men) in the intensive care units at eight different clinical sites were enrolled in the study. Pupillary examination was performed using a portable hand-held pupillometer. Results Patients with abnormal pupillary light reactivity had an average peak ICP of 30.5 mmHg versus 19.6 mmHg for the normal pupil reactivity population (P = 0.0014). Patients with “nonreactive pupils” had the highest peaks of ICP (mean = 33.8 mmHg, P = 0.0046). In the group of patients with abnormal pupillary reactivity, we found that the first evidence of pupil abnormality occurred, on average, 15.9 hours prior to the time of the peak of ICP. Conclusions Automated pupillary assessment was used in patients with possible increased ICP. Using NPi, we were able to identify a trend of inverse relationship between decreasing pupil reactivity and increasing ICP. Quantitative measurement and classification of pupillary reactivity using NPi may be a useful tool in the early management of patients with causes of increased ICP.
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Affiliation(s)
- Jeff W Chen
- Department of Neurological Surgery, Legacy Emanuel Hospital, Gantenbein, Portland, OR 97227
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Reducing Time-to-Treatment Decreases Mortality of Trauma Patients with Acute Subdural Hematoma. Ann Surg 2011; 253:1178-83. [DOI: 10.1097/sla.0b013e318217e339] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tsang KKT, Whitfield PC. Traumatic brain injury: review of current management strategies. Br J Oral Maxillofac Surg 2011; 50:298-308. [PMID: 21530028 DOI: 10.1016/j.bjoms.2011.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 03/17/2011] [Indexed: 11/26/2022]
Abstract
Head injury is a common condition with a high morbidity and mortality. Serious intracranial haematomas require early recognition and evacuation to maximise chances of independent outcomes. Recent organisational changes have promoted the development of trauma units and major trauma centres where patients can go through triage and be managed in an appropriate environment, and the development of management pathways in intensive treatment units has resulted in improvements in the outcome of traumatic brain injuries. Evidence for the treatment of cerebral perfusion pressure, and management of hyperventilation, osmotherapy, tracheostomy, and leakage of cerebrospinal fluid (CSF) has accumulated during the last decade and is important in the management of patients in all clinical settings. Since head injury is commonly associated with maxillofacial injuries, this review will be relevant to all who deal with this aspect of trauma.
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Affiliation(s)
- Kevin King-Tin Tsang
- Derriford Hospital, Department of Neurosurgery, Derriford Road, Plymouth PL6 8DH, United Kingdom.
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Risk Factors Related to Prognosis in Patients with Isolated Traumatic Subdural Hematoma. ACTA ACUST UNITED AC 2011. [DOI: 10.13004/jknts.2011.7.1.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Infrared pupillometry. Basic principles and their application in the non-invasive monitoring of neurocritical patients. Neurologia 2010; 28:41-51. [PMID: 21163229 DOI: 10.1016/j.nrl.2010.07.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 07/08/2010] [Accepted: 07/13/2010] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Pupil assessment is a fundamental part of the neurological examination. Size and reactivity to light of each pupil should be recorded periodically since changes in these parameters may represent the only detectable sign of neurological deterioration in some patients. However, there is great intraobserver and interobserver variability in pupil examination due to the influence of many factors, such as the difference in ambient lighting, the visual acuity and experience of the examiner, the intensity of the luminous stimulus, and the method used to direct this stimulus. In recent years, digital cameras have incorporated infrared devices allowing the development of user-friendly portable devices that permit repeated, non-invasive examinations of pupil size and its reactivity to light with an objective, accessible and inexpensive method. DEVELOPMENT The purpose of this review is to describe the fundamentals of infrared pupillometry and discuss potential applications in the monitoring of neurocritical patients. We also present some recommendations in the routine assessment of pupils in neurocritical patients. CONCLUSIONS The possibility of evaluating the changes in pupil reactivity in an early, objective and almost continuous way provides a new non-invasive monitoring method. This method could improve the predictive factor of neurological deterioration and the bedside monitoring of the neurological state of the patient, avoiding unnecessary examinations and enabling early therapeutic intervention.
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Malmivaara K, Hernesniemi J, Salmenperä R, Ohman J, Roine RP, Siironen J. Survival and outcome of neurosurgical patients requiring ventilatory support after intensive care unit stay. Neurosurgery 2009; 65:530-7; discussion 537-8. [PMID: 19687698 DOI: 10.1227/01.neu.0000350861.97585.ce] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to analyze the clinical outcome of severely ill neurosurgical patients whose need for artificial life support was extended. We sought to determine whether these patients benefit from extended treatment both in life expectancy and quality of life. Furthermore, we evaluated the direct cost of the neurosurgical treatment. METHODS The study group comprised a consecutive series of 346 neurosurgical patients in poor condition who were discharged from the intensive care unit but still in need of artificial respiratory support. The patients had various neurosurgical diagnoses and were treated between 2000 and 2003 at the Department of Neurosurgery, Helsinki University Central Hospital. We followed the outcome of these patients by specially formatted questionnaires 6 months and 1, 2, and 5 years after treatment. Their health-related quality of life was evaluated with EuroQol EQ-5D; quality-adjusted life years (QALY) gained with the treatment and the costs of a QALY were calculated. RESULTS The median follow-up time was 5 years. The mortality rate was 27% at 30 days, 45% at 1 year, and 59% at 5 years after treatment. Of the patients, 20% had a good recovery (Glasgow Outcome Scale [GOS] scores 4 and 5), 18% had severe disability (GOS score 3), none was in a vegetative state (GOS score 2), 59% were dead (GOS score 1), and 3% were lost to follow-up. Of the survivors, 69% lived at home, 22% in a nursing home, 2% were in a hospital, and 7% were lost to follow-up. The median EQ-5D index value was lower than the median index value for the general population: 0.71 (25th percentile [Q1] 0.38 and 75th percentile [Q3] 0.85) versus 0.85 (Q1 0.73 and Q3 1.00). The median cost of the direct neurosurgical treatment per patient was 15,000 euros (25th percentile, 10,000 euros 75th percentile, 22,000 euros). Surviving patients gained a mean of 17 +/- 13 QALYs. The cost of 1 QALY was 2521 euros. CONCLUSION Prolonged intensive care unit and step-down unit treatment of critically ill neurosurgical patients seems to be clinically justified. Moreover, direct costs of neurosurgical treatment were reasonably low.
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Affiliation(s)
- Kirsi Malmivaara
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
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Outcome of brain trauma patients who have a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils in the field. Eur J Emerg Med 2009; 16:153-8. [PMID: 19282759 DOI: 10.1097/mej.0b013e32832a0864] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the outcome of brain trauma patients who had a Glasgow Coma Scale score (GCS) of 3 and bilateral fixed and dilated pupils (BFDP) in the field. METHODS Between January 2001 and December 2005, 13 European centres enrolled patients with severe brain trauma. Data sets of all patients who had a GCS of 3 as well as BFDP were analysed. Patients were classified according to the Glasgow Outcome Scale, 12 months after trauma as 'good' (Glasgow Outcome Scale of 5 or 4) or 'poor' functional recovery; relevant data for these two groups were compared. Variables that showed differences in univariate analyses (chi and Wilcoxon-Mann-Whitney tests) were then used as covariates in logistic regression models. A P value of less than 0.05 was considered significant. RESULTS Ninety-two (7.8%) of 1172 patients had a GCS of 3 and BFDP; eight had 'good', 84 had 'poor' recovery. We found no significant differences in sex (79% male), age (median 32 years), and trauma mechanisms. Trauma was significantly less severe, probability of survival significantly higher (0.48 vs. 0.23) in the 'good' group. Only one of 39 patients who had closed basal cisterns on the first computed tomography scan, and none of the patients with midline shift greater than 15 mm had good outcomes. Logistic regression revealed that age, trauma severity, and status of basal cisterns on the first computed tomography scan were the factors determining outcomes. CONCLUSION Patients with a GCS of 3 and BFDP in the field should be resuscitated aggressively, especially if the trauma seems to be not too severe.
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Aarabi B, Hesdorffer DC, Simard JM, Ahn ES, Aresco C, Eisenberg HM, McCunn M, Scalea T. Comparative study of decompressive craniectomy after mass lesion evacuation in severe head injury. Neurosurgery 2009; 64:927-39; discussion 939-40. [PMID: 19287327 DOI: 10.1227/01.neu.0000341907.30831.d2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE This study was conducted to evaluate outcome after decompressive craniectomy (DC) in the setting of mass evacuation with or without intracranial pressure (ICP) monitoring. METHODS Over a 48-month period (March 2000 to March 2004), 54 of 967 consecutive head injury patients underwent DC for evacuation of a mass lesion. DC was performed without ICP monitoring in 27 patients who required urgent decompression (group A) and in 27 patients who did not require urgent surgery and who had their ICP monitored for 1 to 14 days before surgery (group B). RESULTS In group A, the mean Glasgow Coma Scale score was 6.0; 80% had computed tomographic evidence of a shift greater than 5 mm; and 25 patients underwent DC immediately after resuscitation. In group B, the mean Glasgow Coma Scale score was 7.3; 40% had computed tomographic evidence of shift; and 75% underwent DC 24 hours or longer after presentation. Overall, 22 patients died (12 in group A and 10 in group B), 11 remained vegetative or severely disabled (3 in group A and 8 in group B), and 19 had good recovery (11 in group A and 8 in group B). Two patients were lost to follow-up. In 18 group B patients with ICP greater than 20 mm Hg before mass evacuation, ICP dropped an average of 13 mm Hg (P < 0.001). A mass lesion greater than 50 mL (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.04-7.89) and evidence of low attenuation on computed tomography before (OR, 3.3; 95% CI, 1.1-10.3) or after (OR, 2.92; 95% CI, 1.02-8.34) DC were predictors of death. A good outcome occurred in 42% of patients with and in 63% of patients without delayed traumatic injury (OR, 0.3; 95% CI, 0.1-1.1). Outcome was favorable in 78.6% of patients who had no ICP monitoring before DC versus 47.1% of patients with ICP monitoring (OR, 0.2; 95% CI, 0.1-1.2). CONCLUSION In this study, mortality after DC for mass lesion was greater than expected, and outcome did not differ between patients with or without ICP monitoring.
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Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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