Hydrocephalus despite extra ventricular drainage in adults: a new description of multiloculated hydrocephalus.

Multiloculated hydrocephalus constitutes a challenging pathology due to intracerebral haemorrhage or ventriculitis leading to iterative shunt revision frequently described in paediatric neurosurgery, but poorly reported in adults. Nevertheless, this potential complication of intraventricular haemorrhage, already drained in emergency, should be considered with special interest, as ideal management of cerebrospinal drainage remains debated in such situation. We thus report herein the case of intraventricular haemorrhage in an adult complicated of multiloculated hydrocephalus, as an illustrative plea for endoscopic surgery.

Withholding and withdrawal of life-sustaining therapy in 8569 trauma patients: A multicentre, analytical registry study.

BACKGROUND: This study aimed to determine the prevalence of withholding or withdrawal of life-sustaining therapy (WLST) decisions in trauma ICU patients, using a large registry. We hypothesised that this prevalence is similar to that of the general population admitted to an ICU. As secondary aims, it sought to describe the trauma patients for whom the decision was made for WLST and the factors associated with this decision. DESIGN: This observational study assessed data from 14 French centres listed in the TraumaBaseTM registry. All trauma patients hospitalised for more than 48 h were pro-spectively included. RESULTS: Data from 8569 trauma patients, obtained from January 2016 to December 2018, were included in this study. A WLST decision was made in 6% of all cases. In the WLST group, 67% of the patients were older men (age: 62 versus 36, P  < 0.001); more often they had a prior medical history and higher median severity scores than the patients in the no WLST decision group; SAPS II 58 (46 to 69) versus 21 (13 to 35) and ISS 26 (22 to 24) versus 12 (5 to 22), P  < 0.001. Neurological status was strongly associated with WLST decisions. The geographic area of the ICUs affected the rate of the WLST decisions. The ICU mortality was 11% (n = 907) of which 47% (n = 422) were preceded by WLST decisions. Fourteen percent of WLST orders were not associated to the death. CONCLUSION: Among 8569 patients, medical history, trauma severity criteria, notably neurological status and geographical areas were associated with WLST. These regional differences deserve to be investigated in future studies.

Ability of Fibrin Monomers to Predict Progressive Hemorrhagic Injury in Patients with Severe Traumatic Brain Injury.

BACKGROUND: Progressive hemorrhagic injury (PHI) is common in patients with severe traumatic brain injury (TBI) and is associated with poor outcomes. TBI-associated coagulopathy is frequent and has been described as risk factor for PHI. This coagulopathy is a dynamic process involving hypercoagulable and hypocoagulable states either one after the other either concomitant. Fibrin monomers (FMs) are a direct marker of thrombin action and thus reflect coagulation activation. This study sought to determine the ability of FM to predict PHI after severe TBI. METHODS: We conducted a prospective, observational study including all severe TBI patients admitted in the trauma center. Between September 2011 and September 2016, we enrolled patients with severe TBI into the derivation cohort. Between October 2016 and December 2018, we recruited the validation cohort on the same basis. Study protocol included FM measurements and standard coagulation test at admission and two computed tomography (CT) scans (upon arrival and at least 6 h thereafter). A PHI was defined by an increment in size of initial lesion (25% or more) or the development of a new hemorrhage in the follow-up CT scan. Multivariate logistic regression analysis was applied to identify predictors of PHI. RESULTS: Overall, 106 patients were included in the derivation cohort. Fifty-four (50.9%) experienced PHI. FM values were higher in these patients (151 [136.8-151] vs. 120.5 [53.3-151], p < 0.0001). The ROC curve demonstrated that FM had a fair accuracy to predict the occurrence of PHI with an area under curve of 0.7 (95% CI [0.6-0.79]). The best threshold was determined at 131.7 µg/ml. In the validation cohort of 54 patients, this threshold had a negative predictive value of 94% (95% CI [71-100]) and a positive predictive value of 49% (95% CI [32-66]). The multivariate logistic regression analysis identified 2 parameters associated with PHI: FM ≥ 131.7 (OR 6.8; 95% CI [2.8-18.1]) and Marshall category (OR 1.7; 95% CI [1.3-2.2]). Coagulopathy was not associated with PHI (OR 1.3; 95% CI [0.5-3.0]). The proportion of patients with an unfavorable functional neurologic outcome at 6-months follow-up was higher in patients with positive FM: 59 (62.1%) versus 16 (29.1%), p < 0.0001. CONCLUSIONS: FM levels at admission had a fair accuracy to predict PHI in patients with severe TBI. FM values ≥ 131.7 µg/ml are independently associated with the occurrence of PHI.

Evaluation and Comparison of Different Prehospital Triage Scores of Trauma Patients on In-Hospital Mortality.

Introduction: Several prehospital major trauma patient triage scores have been developed, the triage revised trauma score (T-RTS), Vittel criteria, Mechanism/Glasgow Coma Scale/Age/Systolic blood pressure score (MGAP), and the new trauma score (NTS). These scoring schemes allow a rapid and accurate prognostic assessment of the severity of potential lesions. The aim of our study was to compare these scores with in-hospital mortality predictions in a cohort of consecutive trauma patients admitted in a Level 1 trauma center. Materials: Between 2013 and 2016, 1,112 patients were admitted to the "major trauma" spinneret of a Level 1 trauma center in the south of France. All prehospital data needed to calculate the T-RTS, Vittel criteria, the MGAP score, and the NTS were collected. The main evaluation criterion was in-hospital mortality at 30 days for all causes. The predictive performances of these scores were evaluated and compared with each other using the analysis of the receiver operating curves. Results: A total of 1,001 patients were included in the analysis, 238 (24%) females, aged 43 ± 19 years with ISS 15 ± 13. The area under the curve was for each score: T-RTS, AUC = 0.84, [0.82-0.87]; Vittel criteria, AUC = 0.87 [0.85-0.89]; MGAP score, AUC = 0.91 [0.89-0.92] and NTS, AUC = 0.90 [0.88-0.92]. By comparing the ROC curves of these scores, the MGAP and NTS scores were statistically higher than the T-RTS. With the current thresholds, the sensitivity, specificity, positive and negative predictive values of these scores were 91%, 35%, 10%, 98% for T-RTS, 100%, 2%, 8%, 100% for Vittel criteria, 91%, 71%, 24%, 99% for MGAP score, 82%, 86%, 33%, 98% for NTS. Only Vittel's criteria allowed undertriage below 5% as recommended by the American College of Surgeons Committee on Trauma (ACSCOT). Conclusion: The comparison of these different triage scores concluded with a superiority of the MGAP and NTS scores compared with the T-RTS. Including the calculation of MGAP or NTS scores with the Vittel criteria would reduce the risk of overtriage in the Level 1 trauma centers by further directing patients at low risk of death to a lower-level trauma facility.

Spontaneous Hyperventilation in Severe Traumatic Brain Injury: Incidence and Association with Poor Neurological Outcome.

BACKGROUND: Hypocapnia induces cerebral vasoconstriction leading to a decrease in cerebral blood flow, which might precipitate cerebral ischemia. Hypocapnia can be intentional to treat intracranial hypertension or unintentional due to a spontaneous hyperventilation (SHV). SHV is frequent after subarachnoid hemorrhage. However, it is understudied in patients with severe traumatic brain injury (TBI). The objective of this study was to describe the incidence and consequences on outcome of SHV after severe TBI. METHODS: We conducted a retrospective, observational study including all intubated TBI patients admitted in the trauma center and still comatose 24 h after the withdrawal of sedation. SHV was defined by the presence of at least one arterial blood gas (ABG) with both PaCO2 < 35 mmHg and pH > 7.45. Patient characteristics and outcome were extracted from a prospective registry of all intubated TBI admitted in the intensive care unit. ABG results were retrieved from patient files. A multivariable logistic regression model was developed to determine factors independently associated with unfavorable outcome (defined as a Glasgow Outcome Scale between 1 and 3) at 6-month follow-up. RESULTS: During 7 years, 110 patients fully respecting inclusion criteria were included. The overall incidence of SHV was 69.1% (95% CI [59.9-77]). Patients with SHV were more severely injured (median head AIS score (5 [4-5] vs. 4 [4-5]; p = 0.016)) and exhibited an elevated morbidity during their stay. The proportion of patients with an unfavorable functional neurologic outcome was significantly higher in patients with SHV: 40 (52.6%) versus 6 (17.6%), p = 0.0006. After adjusting for confounders, SHV remains an independent factor associated with unfavorable outcome at the 6-month follow-up (OR 4.1; 95% CI [1.2-14.4]). CONCLUSIONS: SHV is common in patients with a persistent coma after a severe TBI (overall rate: 69%) and was independently associated with unfavorable outcome at 6-month follow-up.

Duret hemorrhage complicating a sinking skin flap syndrome.

Duret hemorrhage has always been reported during an episode of increased intracranial pressure with transtentorial herniation. We reported a Duret hemorrhage occurring during an episode of intracranial hypotension resulted in sinking skin flap syndrome which was responsible for acute paradoxal descending transtentorial herniation and Duret hemorrhage, 10 days after large hemicraniectomy which could indicate early cranioplasty.

Gunshot and stab wounds in France: descriptive study from a national trauma registry.

PURPOSE: Severe trauma is a major problem worldwide. In France, blunt trauma (BT) is predominant and few studies are available on penetrating trauma (PT). The purpose of this study was to perform a descriptive analysis of severe gunshot (GSW) and stab wounds (SW) in patients who were treated in French trauma centers. METHODS: Retrospective study on prospectively collected data in a national trauma registry. All adult (> 15 years) trauma patients primarily admitted in 1 of the 17 trauma centers members of the Traumabase between January 2015 to December 2018 were included. Data from patients who had a PT were compared with those who had suffered a BT over the same period. Due to the known differences between GSW and SW, sub-group analyses on data from GSW, SW and BT were also performed. RESULTS: 8128 patients were included. Twelve percent of the study group had a PT. The main mechanism of PT was SW (68.1%). Five hundred and eighty patients with PT (59.4%) required surgery within the first 24 h. Severe hemorrhage was more frequent in penetrating traumas (11.2% vs. 7.8% p < 0.001). Hospital mortality following PT was 8.9% vs 11% for blunt trauma (p = 0.047). Among PT the mortality after GSW was ten times higher than after SW (23.8% vs 2%). CONCLUSION: This work is the largest study to date that has specifically focused on GSW and SW in France, and will help improving knowledge in managing such patients in our country.

Rotating Hinge Knee Arthroplasty for Revision Prosthetic-Knee Infection: Good Functional Outcomes but a Crucial Need for Superinfection Prevention.

Introduction: Management of chronic infection following total knee arthroplasty (TKA) is challenging. Rotating hinged prostheses are often required in this setting due to severe bone loss, ligamentous insufficiency, or a combination of the two. The nature of the mechanical and septic complications occurring in this setting has not been well-described. The aim of this study was to evaluate patient outcomes using a hinge knee prosthesis for prosthetic knee infections and to investigate risk factors for implant removal. Methods: This was a retrospective cohort study that included all patients treated in our tertiary level referral center between January 2009 and December 2016 for prosthetic knee infection with a hinge knee prosthesis. Only patients with a minimum 2-year of follow-up were included. Functional evaluation was performed using international knee society (IKS) "Knee" and "Function" scores. Survival analysis comparing implant removal risks for mechanical and septic causes was performed using Cox univariate analysis and Kaplan-Meier curves. Risk factors for implant removal and septic failure were assessed. Results: Forty-six knees were eligible for inclusion. The majority of patients had satisfactory functional outcomes as determined by mean IKS scores (mean knee score: 70.53, mean function score: 46.53 points, and mean knee flexion: 88.75°). The 2-year implant survival rate was 89% but dropped to 65% at 7 years follow-up. The risk of failure (i.e., implant removal) was higher for septic etiology compared to mechanical causes. Patients with American society of anesthesiologists (ASA) score>1, immunosuppression, or with peripheral arterial diseases had a higher risk for septic failure. Patients with acute infection according to the Tsukayamaclassification had a higher risk of failure. Of the 46 patients included, 19 (41.3%) had atleast one infectious event on the surgical knee and most of these were superinfections (14/19) with new pathogens isolated. Among pathogens responsible for superinfections (i) cefazolin and gentamicin were both active in six of the cases but failed to prevent the superinfection; (ii) cefazolin and/or gentamicin were not active in eight patients, leading to alternative systemic and/or local antimicrobial prophylaxis consideration. Conclusions: Patients with chronic total knee arthroplasty (TKA) infection, requiring revision using rotating hinge implant, had good functional outcomes but experienced a high rate of septic failure, mostly due to bacterial superinfection. These patients may need optimal antimicrobial systemic prophylaxis and innovative approaches to reduce the rate of superinfection.

Validation of a monitoring matrix for patients with brain injuries.

BACKGROUND: Brain injury is a leading cause of death and disabilities worldwide. The severity of brain damage is of course related to the primary injury. Secondary brain insults are the most powerful determinants of outcome from severe head injury. To improve the outcome, it needs to be well detected to be controlled. The detection of these factors can be difficult among numerous data. The objective of this work was to validate a monitoring matrix to help this screening. We hypothesise that a monitoring matrix will improve the detection rate of factors linked to secondary brain injury (SBI). METHOD: We conducted a single-center prospective observational simulation study. We designed a monitoring matrix compiling all the brain insults, intracranial data (ICP, CCP, PtiO2) and systemic data (PaCO2, PaO2, temperature, natremia, hemoglobin). Each caregiver had to analyze the same simulated data with a standard monitoring sheet and with the monitoring matrix. We then compared the detection rate of SBI factors. RESULTS: 25 caregivers analyzed a total of 265 matrixes. The monitoring matrix had a sensitivity of 96.5% and a specificity of 99.9% versus 69.9% and 67.8% respectively for the standard monitoring sheet. The detection rate was significantly higher with the monitoring matrix (96.5%) versus the standard monitoring sheet (69.9%), regardless of the caregiver's status. It is also improved among nurses, regardless of their seniority. CONCLUSION: The use of this monitoring matrix is simple and inexpensive. The monitoring matrix improves significantly the detection rate of factors linked to secondary brain injury. It also provides homogenization of the detection rate among the physicians and nurses regardless of their experience. Nurses becoming as qualified as physicians, allows earlier detection and therefore a faster treatment.

Correlation between field triage criteria and the injury severity score of trauma patients in a French inclusive regional trauma system.

BACKGROUND: In France, the pre-hospital field triage of trauma patients is currently based on the Vittel criteria algorithm. This algorithm was originally created in 2002 before the stratification of trauma centers and, at the national level, has not been revised since. This could be responsible for the overtriage of trauma patients in Level I Trauma Centers. The principal aim of this study was to evaluate the correlation between each Vittel field triage criterion and trauma patients' Injury Severity Score. METHODS: Our Level I Trauma Center receives an average of 300 trauma patients per year. Demographic and physiological data, along with the entire trauma patient management process and Vittel field triage criteria, are recorded in a local trauma registry. The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are calculated after a complete assessment of the trauma victim during their in-hospital management. Results were concerned with the presence of an ISS of greater than 15, which defined a major trauma patient; mortality within 30 days; and admission to the intensive care unit. This study is a registry analysis from January 2013 to September 2017. RESULTS: Of the 1373 patients in the registry, 1151 were included in the analysis with a mean age of 43 years (± 19) and a median ISS of 13 (IQR = 5-22), where 887 (77%) were male. Nine of the 24 Vittel criteria were associated with an ISS > 15. In a multivariate analysis, no criterion related to kinetic elements was significantly correlated with an ISS > 15, mortality within 30 days, or admission to intensive care. Three algorithm categories were predictive of a major trauma patient (ISS > 15): physiological variables, pre-hospital resuscitation, and physical injuries, while kinetic elements were not. CONCLUSIONS: Criteria related to physiological variables, pre-hospital resuscitation, and physical injuries are the most relevant to predicting the severity of a trauma patient's condition. A revision of the VCA could potentially have beneficial effects on the over and undertriage phenomena, which constitute ongoing medical and financial concerns.

Blunt cerebrovascular injuries in severe traumatic brain injury: incidence, risk factors, and evolution.

OBJECTIVE Blunt cerebrovascular injuries (BCVIs) affect approximately 1% of patients with blunt trauma. An antithrombotic or anticoagulation therapy is recommended to prevent the occurrence or recurrence of neurovascular events. This treatment has to be carefully considered after severe traumatic brain injury (TBI), due to the risk of intracranial hemorrhage expansion. Thus, the physician in charge of the patient is confronted with a hemorrhagic and ischemic risk. The main objective of this study was to determine the incidence of BCVI after severe TBI. METHODS The authors conducted a prospective, observational, single-center study including all patients with severe TBI admitted in the trauma center. Diagnosis of BCVI was performed using a 64-channel multidetector CT. Characteristics of the patients, CT scan results, and outcomes were collected. A multivariate logistic regression model was developed to determine the risk factors of BCVI. Patients in whom BCVI was diagnosed were treated with systemic anticoagulation. RESULTS In total, 228 patients with severe TBI who were treated over a period of 7 years were included. The incidence of BCVI was 9.2%. The main risk factors were as follows: motorcycle crash (OR 8.2, 95% CI 1.9-34.8), fracture involving the carotid canal (OR 11.7, 95% CI 1.7-80.9), cervical spine injury (OR 13.5, 95% CI 3.1-59.4), thoracic trauma (OR 7.3, 95% CI 1.1-51.2), and hepatic lesion (OR 13.3, 95% CI 2.1-84.5). Among survivors, 82% of patients with BCVI received systemic anticoagulation therapy, beginning at a median of Day 1.5. The overall stroke rate was 19%. One patient had an intracranial hemorrhagic complication. CONCLUSIONS Blunt cerebrovascular injuries are frequent after severe TBI (incidence 9.2%). The main risk factors are high-velocity lesions and injuries near cervical arteries.

Pulmonary oedema in breath-hold diving: an unusual presentation and computed tomography findings.

Haemoptysis and pulmonary oedema following deep breath-hold diving have been described in recent years. We describe the case of a 33-year-old healthy military diver who presented symptoms suggestive of pulmonary oedema after two breathhold dives, the first lasting 0.5-1 min and the second 1-2 min, to 6 metres' depth in the sea. The diagnosis was promptly confirmed with chest computed tomography showing bilateral interstitial infiltrates in the upper regions of the lungs. To our knowledge, this is the first report to document pulmonary oedema in this setting of shallow breath-hold diving with atypical radiological presentation. A definite mechanism for this specific distribution of lung injury remains unclear.