Cisternostomy is not beneficial to reduce the occurrence of post-traumatic hydrocephalus in Traumatic Brain Injury.

BACKGROUND: The Cisternostomy is a novel surgical concept in the treatment of Traumatic Brain Injury (TBI), which can effectively drain the bloody cerebrospinal fluid from the skull base cistern, reduce the intracranial pressure, and improve the return of bone flap, but its preventive role in post-traumatic hydrocephalus (PTH) is unknow. The purpose of this paper is to investigate whether Cisternostomy prevents the occurrence of PTH in patients with moderate and severe TBI. METHODS: A retrospective analysis of clinical data of 86 patients with moderate and severe TBI from May 2019 to October 2021 was carried out in the Brain Trauma Center of Tianjin Huanhu Hospital. Univariate analysis was performed to examine the gender, age, preoperative Glasgow Coma Scale (GCS) score, preoperative Rotterdam CT score, decompressive craniectomy rate, intracranial infection rate, the incidence of subdural fluid, and incidence of hydrocephalus in patients between the Cisternostomy group and the non-Cisternostomy surgery group. we also analyzed the clinical outcome indicators like GCS at discharge,6 month GOS-E and GOS-E ≥ 5 in two groups.Additionaly, the preoperative GCS score, decompressive craniectomy rate, age, and gender of patients with PTH and non hydrocephalus were compared. Further multifactorial logistic binary regression was performed to explore the risk factors for PTH. Finally, we conducted ROC curve analysis on the statistically significant results from the univariate regression analysis to predict the ability of each risk factor to cause PTH. RESULTS: The Cisternostomy group had a lower bone flap removal rate(48.39% and 72.73%, p = 0.024)., higer GCS at discharge(11.13 ± 2.42 and 8.93 ± 3.31,p = 0.000) and better 6 month GOS-E(4.55 ± 1.26 and 3.95 ± 1.18, p = 0.029)than the non-Cisternostomy group However, there was no statistical difference in the incidence of hydrocephalus between the two groups (25.81% and 30.91%, p = 0.617). Moreover, between the hydrocephalus group and no hydrocephalus group,there were no significant differences in the incidence of gender, age, intracranial infection, and subdural fluid. While there were statistical differences in peroperative GCS score, Rotterdam CT score, decompressive craniectomy rate, intracranial infection rate, and the incidence of subdural fluid in the two groups, there was no statistical difference in the percentage of cerebral cisterns open drainage between the hydrocephalus group and no hydrocephalus group (32.00% and 37.70%, p = 0.617). Multifactorial logistic binary regression analysis results revealed that the independent risk factors for PTH were intracranial infection (OR = 18.460, 95% CI: 1.864-182.847 p = 0.013) and subdural effusion (OR = 10.557, 95% CI: 2.425-35.275 p = 0.001). Further, The ROC curve analysis showed that peroperative GCS score, Rotterdam CT score and subdural effusion had good ACU(0.785,0.730,and 0.749), with high sensitivity and specificity to predict the occurrence of PTH. CONCLUSIONS: Cisternostomy may decrease morbidities associated with removal of the bone flap and improve the clinical outcome, despite it cannot reduce the disability rate in TBI patients.Intracranial infection and subdural fluid were found to be the independent risk factors for PTH in patients with TBI,and the peroperative GCS score, Rotterdam CT score and subdural effusion had higher sensitivity and specificity to predict the occurrence of PTH. And more importantly, no correlation was observed between open drainage of the cerebral cisterns and the occurrence of PTH, indicating that Cisternostomy may not be beneficial in preventing the occurrence of PTH in patients with moderate and severe TBI.

An Analysis of Emergency Surgical Outcomes for Pediatric Traumatic Brain Injury: A Ten-Year Single-Institute Retrospective Study in Taiwan.

Background and Objectives: Pediatric traumatic brain injury (pTBI) remains a major pediatric public health problem, despite well-developed injury prevention programs. The purpose of this study is to analyze the emergency surgical outcomes of pTBI in a single institute ten-year retrospective study to offer a real-world clinical result. Materials and Methods: Our institute presented a clinical retrospective, single-institute research study of 150 pediatric TBI cases that were diagnosed and underwent emergency surgical treatment from 2010 to 2019. Results: The incidence of radiological findings is detailed as follows: brain edema (30%, 45/150), followed by acute subdural hematoma (27.3%, 41/150), epidural hematoma (21.3%, 32/150), chronic subdural hemorrhage (10%, 15/150), skull fracture (6.7%, 10/150), and traumatic subarachnoid hemorrhage (4.7%, 7/150). Surgical intervention data revealed that decompressive craniectomy was still the main effective surgical method. The results showed longer hospital stays and higher morbidity rates in the brain edema, acute subdural hematoma, and chronic subdural hemorrhage groups, which were viewed as poor surgical outcome groups. Epidural hematoma, skull fracture and traumatic subarachnoid hemorrhage were categorized into good surgical outcome groups. Notably, the data revealed gross improvement in Glasgow Coma Scale/Score (GCS) evolution after surgical interventions, and the time to cranioplasty was a significant factor in the development of post-traumatic hydrocephalus (PTH). Conclusions: Our study provided real-world data for the distribution of etiology in pTBI and also categorized it into six groups, indicating disease-orientated treatment. In addition, our data supported that decompressive craniectomy (DC) remains a mainstay surgical treatment in pTBI and early cranioplasty could decrease the incidence of PTH.

Development of normal pressure hydrocephalus following post-traumatic external hydrocephalus in an adult patient.

We report the case of 74-year-old patient suspected of post-traumatic external hydrocephalus (EH) following a mild traumatic brain injury with a progressive neurological decline and a concomitant enlargement of subarachnoid spaces without ventriculomegaly on CT scan. A lumbar puncture revealed raised ICP and a careful CSF withdrawal was performed, resulting in an immediate neurological improvement, confirming the diagnosis of EH. During the 20-month follow-up, the patient presented progressive signs of normal pressure hydrocephalus (NPH): gait and cognitive decline, ventriculomegaly and the lumbar infusion study confirmed disturbed CSF dynamics. The patient underwent a ventriculoperitoneal shunt surgery, resulting in a long-lasting improvement.

[Surgical treatment of patients with skull defects and cerebrospinal fluid flow disorders after previous decompressive craniectomy]. / Taktika khirurgicheskogo lecheniya patsientov s defektami cherepa posle dekompressivnoi kranioektomii i s likvorodinamicheskimi narusheniyami.

Decompressive craniectomy (DC) is performed for refractory intracranial hypertension following severe traumatic brain injury, vascular and oncological diseases. This fact increases the number of patients with extensive and giant skull defects. Cerebrospinal fluid (CSF) flow disorders after DC are often accompanied by ventriculomegaly. However, only some patients with ventriculomegaly have hydrocephalus and require CSF bypass procedures. Differentiation of post-traumatic hydrocephalus requiring surgical treatment and atrophic dilation of ventricular system «ex vacuo¼ caused by brain injury is still an important issue. Skull sealing as a way to normalize CSF circulation and eliminate hydrocephalus is also an open question. Currently, there is no unified approach to patients with extensive and giant cranial defects combined with post-traumatic hydrocephalus. There is no unified algorithm for sequence of reconstructive and CSF bypass operations in these patients. Literature data on risks of infectious complications for different surgical strategies are controversial.

Experiences of family caregivers of patients with post-traumatic hydrocephalus from hospital to home: a qualitative study.

BACKGROUND: Post-traumatic hydrocephalus (PTH) is a complication of traumatic brain injury (TBI) that requires treatment and postoperative care. The shunt is one of the main treatments for PTH, which presents with dysfunction and infection. Considering brain injury, hydrocephalus shunt malfunction, and infection, family caregivers need to be responsible for caring for PTH patients, recognizing shunt malfunction and infection, and managing those patients accordingly from hospital to home. Understanding the experiences and needs of caregivers is beneficial for knowing their competency and quality of health care, ameliorating and ensuring future transition care. The study aimed to explore the feelings, experiences, and needs of family caregivers when caring for patients with TBI, PTH and shunts. METHODS: This was exploratory research of a purposive sample of 12 family caregivers of adult patients with TBI, PTH and shunts in five neurosurgery departments at a general hospital in Zhengzhou, Henan Province, China, using a semi-structured interview method. Data were collected from October 2021 to March 2022 before being analyzed by content analysis methods. RESULTS: Caregivers required professional and social knowledge and support in the areas of TBI, PTH and shunts, caregiving interventions, psychological care needs, and health insurance, just as caregivers do, but unlike other general caregivers, care for patients with TBI, PTH, and shunt is fraught with uncertainty and the need to manage shunt setting, and caregivers often experience 'complex emotional reaction' during the transitional period, where care needs and complex emotions may lead to a lack of caregiver confidence, which in turn may affect caregiving behaviors, and experiences that affect care may be mediated through caregiving confidence. The perceived availability of resources, particularly those that are still available to them when they return home, has a significant impact on participants' emotional response and sense of confidence. CONCLUSIONS: The emotional response and the impact of stressor caregivers after TBI, PTH, and shunt was important, and sometimes confidence in care appeared to be an intermediate and useful factor that needed to be considered as health professionals prepared to develop care resources on how to manage and empower patients with TBI, PTH, and shunt. Meanwhile, there may be gaps and inequities in supportive care for patients diagnosed with TBI, PTH, and shunt in China.

Incidence of surgically treated post-traumatic hydrocephalus 6 months following head injury in patients undergoing acute head computed tomography.

BACKGROUND: Post-traumatic hydrocephalus (PTH) is a well-known complication of head injury. The percentage of patients experiencing PTH in trauma cohorts (0.7-51.4%) varies greatly in the prior literature depending on the study population and applied diagnostic criteria. The objective was to determine the incidence of surgically treated PTH in a consecutive series of patients undergoing acute head computed tomography (CT) following injury. METHODS: All patients (N = 2908) with head injuries who underwent head CT and were treated at the Tampere University Hospital's Emergency Department (August 2010-July 2012) were retrospectively evaluated from patient medical records. This study focused on adults (18 years or older) who were residents of the Pirkanmaa region at the time of injury and were clinically evaluated and scanned with head CT at the Tampere University Hospital's emergency department within 48 h after injury (n = 1941). A thorough review of records for neurological signs and symptoms of hydrocephalus was conducted for all patients having a radiological suspicion of hydrocephalus. The diagnosis of PTH was based on clinical and radiological signs of the condition within 6 months following injury. The main outcome was surgical treatment for PTH. Clinical evidence of shunt responsiveness was required to confirm the diagnosis of PTH. RESULTS: The incidence of surgically treated PTH was 0.15% (n = 3). Incidence was 0.08% among patients with mild traumatic brain injury (TBI) and 1.1% among those with moderate to severe TBI. All the patients who developed PTH underwent neurosurgery during the initial hospitalization due to the head injury. The incidence of PTH among patients who underwent neurosurgery for acute traumatic intracranial lesions was 2.7%. CONCLUSION: The overall incidence of surgically treated PTH was extremely low (0.15%) in our cohort. Analyses of risk factors and the evaluation of temporal profiles could not be undertaken due to the extremely small number of cases.

Atorvastatin treatment in a patient with post-traumatic hydrocephalus: a case report.

OBJECTIVES: Clinical treatment of post-traumatic hydrocephalus (PTH) is limited to cerebrospinal fluid (CSF) extracranial shunting, and research on noninvasive treatment is still lacking. In a follow-up study of a patient with PTH, atorvastatin treatment was beneficial in controlling hydrocephalus and promoting neurological recovery. METHOD: A 29-year-old male patient with traumatic brain injury (TBI) was found to have progressive hydrocephalus and presented with symptoms of decreased spontaneous speech and delayed functional recovery. We added oral treatment with 20 mg/day atorvastatin and followed up hydrocephalus with head CT every two months. RESULTS: The span of the third ventricle decreased by 21%, Evan's index fell by 16%, and the Fugl-Meyer motor score was up from 17/100 to 56/100. The Montreal Cognitive Assessment score was modified from 15/30 to 23/30. CONCLUSION: The use of atorvastatin in the patient may improve the imaging results and benefit the patient functionally.

Post-traumatic hydrocephalus - incidence, risk factors, treatment, and clinical outcome.

OBJECTIVES: Post-traumatic hydrocephalus (PTH) is well-known after traumatic brain injury (TBI), but there is limited evidence regarding patient selection for ventriculo-peritoneal (VP)-shunt treatment. In this study, we investigated the incidence and risk factors for PTH and the indication for and outcome after shunt treatment. MATERIALS AND METHODS: In this retrospective study, 836 TBI patients, treated at our neurointensive care (NIC) unit at Uppsala university hospital, Sweden, between 2008 and 2018, were included. Demography, admission status, radiology, treatments, and outcome variables were evaluated. RESULTS: Post-traumatic ventriculomegaly occurred in 46% of all patients at NIC discharge. Twenty-nine (3.5%) patients received a VP-shunt. Lower GCS M at admission, greater amount of subarachnoid hemorrhage, meningitis, decompressive craniectomy (DC), and ventriculomegaly at NIC discharge were risk factors for receiving a VP-shunt. Fourteen of the PTH patients showed impeded recovery or low-pressure hydrocephalus symptoms, of whom 13 experienced subjective clinical improvement after shunt treatment. Five PTH patients showed deterioration in consciousness, of whom four improved following shunt treatment. Five DC patients received a shunt due to subdural hygromas (n =2) or external brain herniation (n = 3), of whom two patients improved following treatment. Five patients were vegetative with concurrent ventriculomegaly and these patients did not have any positive shunt response. Altogether, 19 (66%) PTH patients improved after shunt surgery. CONCLUSION: Post-traumatic ventriculomegaly was common, but few developed symptomatic PTH and received a VP-shunt. Patients with low-pressure hydrocephalus symptoms had the best shunt response, whereas patients with suspected vegetative state exhibited a minimal shunt response.

Post-traumatic hydrocephalus may be associated with autologous cranioplasty failure, independent of ventriculoperitoneal shunt placement: a retrospective analysis.

PURPOSE: Decompressive craniectomy (DC) is a common procedure used for the treatment of intracranial hypertension. Once brain swelling has subsided, a cranioplasty is performed to restore cosmesis and protection to the brain. While using the patient's autologous bone flap is often the first choice in cranioplasty, this procedure is frequently complicated by bone flap resorption and infection. This study seeks to identify predictors of autologous cranioplasty failure. METHODS: A retrospective analysis was conducted on patients who underwent decompressive craniectomy and autologous cranioplasty. Patient demographics and factors related to both surgeries and failure rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in autologous cranioplasty failure. RESULTS: In our cohort, 127 patients underwent autologous cranioplasty. Overall, 18 (14.2%) patients experienced autologous cranioplasty failure. Regression analysis identified development of post-traumatic hydrocephalus (PTH) following DC (OR: 3.26, p = 0.043), presence of neurological deficits following DC (OR: 4.88, p = 0.025), and reoperation prior to CP (OR 3.0, p = 0.049) as significant predictors of autologous cranioplasty failure. Of the 16 patients who developed PTH following DC, 9 received a VP shunt. The rate of flap failure was similar across the 9 PTH patients who received a shunt and the 7 PTH patients who did not receive a shunt (33% vs. 57% failure rate, respectively, p = 0.341). CONCLUSION: Autologous cranioplasty is a reasonably successful procedure with a flap failure rate of 14.2%. We identified PTH, persistent neurological deficits, and reoperation prior to cranioplasty as significant predictors of autologous cranioplasty failure. Interestingly, the presence of VP shunt did not impact the odds of flap failure.

Prognostic significance of subdural hygroma for post-traumatic hydrocephalus after decompressive craniectomy in the traumatic brain injury setting: a systematic review and meta-analysis.

Post-traumatic hydrocephalus (PTH) is a potentially morbid sequela of decompressive craniectomy for traumatic brain injury (TBI). Subdural hygromas are commonly identified following decompressive craniectomy, but the clinical relevance and predictive relationship with PTH in this patient cohort is not completely understood. Survey of seven electronic databases from inception to June 2019 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate hazard ratios (HRs) for PTH by the presence of subdural hygroma were extracted and pooled by meta-analysis of proportions with random effects modeling. We systematically identified nine pertinent studies describing outcomes of 1010 TBI patients managed by decompressive craniectomy. Of the overall cohort, there were 211 (21%) females and median age was 37.5 years (range 33-53). On presentation, median Glasgow Coma Scale was 7 (range, 5-8). In sum, PTH was reported in 228/840 (27%) cases, and subdural hygroma was reported in 449/1010 (44%) cases across all studies. Pooling multivariate-derived HRs indicated that subdural hygroma was a significant, independent predictor of PTH (HR, 7.1; 95% CI, 3.3-15.1). The certainty of this association was deemed low due to heterogeneity concerns. The presence of subdural hygroma is associated with increased risk of PTH after decompressive craniectomy among TBI patients based on the current literature and may mandate closer clinical surveillance when detected. Prospective studies, including those of intracranial hydrodynamics following decompressive craniectomy in the setting of TBI, will better validate the certainty of these findings.

Differences in Cerebrospinal Fluid Dynamics in Posttraumatic Hydrocephalus Versus Atrophy, Including Effect of Decompression and Cranioplasty.

INTRODUCTION: Challenges in diagnosing post-traumatic hydrocephalus (PTH) have created a need for an accurate diagnostic tool. We aim to report CSF dynamics in PTH and atrophy, along with differences before and after cranioplasty. METHODS: We retrospectively analyzed traumatic brain injury patients with ventriculomegaly who had infusion studies. We divided patients depending on CSF dynamics into two groups: 'likely PTH' (A) and 'likely atrophy' (B). A group of idiopathic normal pressure hydrocephalus shunt-responsive patients was used for comparison (C). RESULTS: Group A consisted of 36 patients who were non-decompressed or had a cranioplasty in situ for over 1 month. Group B included 16 patients with low Rout, AMP, and dAMP, 9 of whom were decompressed. Rout and dAMP were significantly higher in Group A than B, but significantly lower than Group C (45 iNPH patients). RAP change during infusion in group A indicated depleted compensatory reserve compared to ample reserve in group B. Repeat studies in five decompressed patients post-cranioplasty showed all parameters increased. CONCLUSIONS: Infusion tests are not useful in decompressed patients, whilst cranioplasty allowed differentiation between possible PTH and atrophy. Rout and AMP were significantly lower in PTH compared to iNPH and did not always reflect the degree of hydrocephalus reported on imaging.

Predicting the outcomes of shunt implantation in patients with post-traumatic hydrocephalus and severe conscious disturbance: a scoring system based on clinical characteristics.

Post-traumatic hydrocephalus is a common complication secondary to traumatic brain injury. It can cause cerebral metabolic impairment and dysfunction. Therefore, timely treatment with shunt implantation is necessary. However, the outcomes of shunt surgery in patients with post-traumatic hydrocephalus combined with disturbance of consciousness are doubtful. The objective was to develop a predictive model that uses the information available before surgery to predict the outcome of shunt implantation in such patients. Retrospectively collected data were used to develop a clinical prediction model. The model was derived from 59 patients using logistic regression analysis, and then it was evaluated by the area under the receiver operating characteristic curve and Hosmer-Lemshow test. A validation cohort verified the model. Four independent predictors were identified: age < 50 years, mild hydrocephalus, Glasgow Coma Scale scores 9-12 at the time of injury, and time interval from trauma to shunting < 3 months. We calculated the total score and defined the patients into three groups: low-probability (0-10 points), medium-probability (11-16 points), and high-probability (17-30 points). The rates of improved outcomes in the three groups were 14.3%, 52.6%, and 94.7%, respectively (P < 0.0001). The correlative rates of the validation cohort were 21.4%, 54.5%, and 85.7%. The prognostic model showed good discrimination (area under the receiver operating characteristic curve = 0.869) and calibration (Hosmer-Lemshow test, P = 0.391). The developed predictive model can identify patients with post-traumatic hydrocephalus combined with disturbance of consciousness who can benefit from shunt implantation. Therefore, our prognostic model can predict the outcomes of patients with post-traumatic hydrocephalus and disturbance of consciousness after shunt surgery.

Determinants affecting the prognosis of decompressive craniectomy for traumatic brain injury.

OBJECTIVE: This research was designed to investigate the prognostic determinants of patients with traumatic brain injury (TBI) undergoing decompressive craniectomy (DC). METHODS: The present study was a retrospective single center research including a total of 112 patients undergoing DC for TBI in Liaocheng People's Hospital between January 2017 and December 2018. The results were measured by Extended Glasgow Outcome Sale (GOSE). The prognostic determinants were identified by univariate and binary logistic regression analysis between the deaths and survivors or favorable and unfavorable outcomes. RESULTS: At the six-month follow-up, the mortality was 45.5% including 37 (33.0%) patients died within 30 days. The independent prognostic factors of 30-day mortality were age (p=0.033), D-dimer level at admission (p=0.032) and postoperative hypernatremia (p=0.014). Seventy five patients survived more than 30 days after DC, among which 27 (36.0%) patients had unfavorable prognosis (GOSE 1-4) and 48 (64.0%) patients presented favorable prognosis (GOSE 5-8). After 30 days from DC, the occurrence of post-traumatic hydrocephalus(PTH) (p= 0.008) was associated with unfavorable prognosis. CONCLUSIONS: Although DC is an effective treatment for TBI patients, the mortality and morbidity risk remain high. A combination of age, D-dimer level at admission and postoperative hypernatremia may be a good prognostic factor for 30-day mortality. Developing an accurate therapy strategy to prevent and control PTH may be beneficial to the 6-month prognosis for TBI patients undergoing DC.

[CSF shunting surgery in patients with post-traumatic hydrocephalus in the vegetative status and minimally conscious state: analysis of its efficacy and safety]. / Likvoroshuntiruiushchie operatsii u patsientov s posttravmaticheskoi gidrotsefaliei v vegetativnom statuse i sostoianii minimal'nogo soznaniia: analiz éffektivnosti i bezopasnosti.

The development of post-traumatic hydrocephalus (PTH) after severe traumatic brain injury can cause, in some cases, severe impairment of consciousness and prevent rehabilitation of patients. The influence of cerebrospinal fluid (CSF) circulation disorders on processes of consciousness recovery is a fundamental problem that requires in-depth research. The issues of differential diagnosis, results of surgical treatment of PTH, and its complications in patients in the vegetative status (VS) and minimally conscious state (MCS) remain poorly covered. MATERIAL AND METHODS: We performed a retrospective analysis of the long-term outcomes of surgical treatment in 82 PTH patients in the VS (38 cases) and MCS (44 cases). RESULTS: A significant clinical improvement occurred in 60.6% of VS patients and in 65.9% of MCS patients. The rate of shunt infection was high and amounted to 21.05% in the group of VS patients and 20.4% in the group of MCS patients. The rate of shunt system dysfunction was 26.05% in the first group and 20.4% in the second group. Postoperative mortality (associated directly with treatment complications) was 3.6%. Total mortality was 10.9%. DISCUSSION: The positive effect of shunting surgery in patients with gross impairment of consciousness was associated with transition to higher levels of consciousness. The high rate of complications, especially infections, was due to a serious condition of patients and comorbidities, in particular chronic infection foci. Shunt system dysfunction was not a factor of the adverse outcome of surgical treatment because rarely led to irreversible consequences, but required repeated surgery. Mortality after shunting surgery was significantly higher in patients with gross impairment of consciousness than in other groups of patients. We found a correlation between deaths in VS patients and shunt infection in the postoperative period. CONCLUSION: CSF shunting surgery is an important step in surgical rehabilitation of PTH patients. To assess the contribution of various risk factors to the development of shunt infection and to develop measures reducing its rate, further prospective studies are needed.

Risk factors for post-traumatic hydrocephalus following decompressive craniectomy.

BACKGROUND: Post-traumatic hydrocephalus (PTH) is one of the main complications of decompressive craniectomy (DC) after traumatic brain injury (TBI). Then, the recognition of risk factors and subsequent prompt diagnosis and treatment of PTH can improve the outcome of these patients. The purpose of this study was to identify factors associated with the development of PTH requiring surgical treatment in patients undergoing DC for TBI. METHODS: In this study, we collected the data of 190 patients (149 males and 41 females), who underwent DC for TBI in our Center. Then we analyzed the type of surgical treatment for all patients affected by PTH and the risk factors associated with the development of PTH. RESULTS: Post-traumatic hydrocephalus (PTH) developed in 37 patients out of 130 alive 30 days after DC (28.4%). The development of PTH required ventriculoperitoneal shunt (VPS) in 34 patients out of 37 (91.9%), while, in the remaining 3 patients, cerebrospinal fluid hydrodynamic (CSF) disturbances resolved after urgent cranioplasty and temporary external lumbar drain. Multivariate analysis showed that the presence of interhemispheric hygroma (p < 0.001) and delayed cranioplasty (3 months after DC) (p < 0.001) was significantly associated with the need for a VPS or other surgical procedure for PTH. Finally, among the 130 patients alive after 30 days from DC, PTH was associated with unfavorable outcome as measured by the 6-month Glasgow Outcome Scale score (p < 0.0001). CONCLUSIONS: Our results showed that delayed cranial reconstruction was associated with an increasing rate of PTH after DC. The presence of an interhemispheric hygroma was an independent predictive radiological sign of PTH in decompressed patients for severe TBI.

Using external lumbar CSF drainage to treat communicating external hydrocephalus in adult patients after acute traumatic or non-traumatic brain injury.

BACKGROUND: Despite various treatments to control intracranial pressure (ICP) after brain injury, patients may present a late onset of high ICP or a poor response to medications. External lumbar drainage (ELD) can be considered a therapeutic option if high ICP is due to communicating external hydrocephalus. We aimed at describing the efficacy and safety of ELD used in a cohort of traumatic or non-traumatic brain-injured patients. METHODS: In this multicentre retrospective analysis, patients had a delayed onset of high ICP after the initial injury and/or a poor response to ICP treatments. ELD was considered in the presence of radiological signs of communicating external hydrocephalus. Changes in ICP values and side effects following the ELD procedure were reported. RESULTS: Thirty-three patients with a median age of 51 years (25-75th percentile: 34-61 years) were admitted after traumatic (n = 22) or non-traumatic (n = 11) brain injuries. Their initial Glasgow Coma Scale score was 8 (4-11). Eight patients underwent external ventricular drainage prior to ELD. Median time to ELD insertion was 5 days (4-8) after brain insult. In all patients, ELD was dramatically effective in lowering ICP: 25 mmHg (20-31) before versus 7 mmHg (3-10) after (p < 0.001). None of the patients showed adverse effects such as pupil changes or intracranial bleeding after the procedure. One patient developed an ELD-related infection. CONCLUSIONS: These findings indicate that ELD may be considered potentially effective in controlling ICP, remaining safe if a firm diagnosis of communicating external hydrocephalus has been made.

Subdural hygroma following decompressive craniectomy or non-decompressive craniectomy in patients with traumatic brain injury: Clinical features and risk factors.

OBJECTIVE: Subdural hygroma (SDG) is a common complication that can occur after head trauma or secondary to decompressive craniectomy (DC). SDGs can be located not only ipsilateral or contralateral to the side of the DC, but also bilateral or unilateral in patients without DC. This study investigated the incidence and risk factors for different types of SDG in a large cohort of patients with traumatic brain injury (TBI). METHODS: A retrospective study was conducted involving 379 adult patients with TBI who were admitted to Huashan Hospital, Fudan University between January 2009 and December 2013. As the outcome was dichotomous (SDG vs no SDG or hydrocephalus vs no hydrocephalus), multivariate logistic regression analyses were used to identify independent risk factors for the development of SDGs in patients without DC, ipsilateral SDG after unilateral DC, contralateral SDG after unilateral DC or SDG after bilateral DC. Risk factors for the development of hydrocephalus were also evaluated in patients with and without DC. RESULTS: Among the 207 (54.6%) patients without DC, 30 (14.5%) had unilateral SDGs and 34 (16.4%) had bilateral SDGs. Of the 172 patients (45.4%) with DC, 134 (77.9%) underwent unilateral DC and 38 (22.1%) underwent bilateral DC. Of the 134 patients who underwent unilateral DC, 49 developed SDG, including 22 (16.4%) ipsilateral SDG, 19 (14.2%) contralateral SDG and eight (6.0%) both ipsilateral and contralateral SDGs. For patients undergoing bilateral DC, 13 (34.2%) developed a SDG. No significant difference in the incidence of SDG was observed between the patients with and without DC (36.0% vs 30.9%, p = 0.291), but the characteristics of SDGs were different between the two groups. Logistic regression analysis showed that factors independently associated with the development of SDG were male sex (odds ratio [OR] = 3.861; 95% CI = 1.642-9.091; p = 0.002), older age (OR = 1.046; 95% CI = 1.021-1.070; p < 0.001), basal cistern haemorrhage (OR = 4.608; 95% CI = 1.510-14.064; p = 0.007), diffuse injury and swelling (OR = 3.158; 95% CI = 1.341-7.435; p = 0.008) or diffuse injury and shift (OR = 3.826; 95% CI = 1.141-12.830; p = 0.030) in patients without DC. Temporal haematoma or contusion in the non-DC side (OR = 2.623; 95% CI = 1.070-6.428; p = 0.035) and traumatic SAH (OR = 3.751; 95% CI = 1.047-13.438; p = 0.042) were independently associated with the development of ipsilateral SDG in patients who underwent unilateral DC. However, factors independently associated with the development of contralateral SDG were frontal haematoma or contusion on the non-DC side (OR = 3.145; 95% CI = 1.272-7.774; p = 0.013) and SDH on the non-DC side (OR = 7.024; 95% CI = 1.477-33.390; p = 0.014). Only craniectomy area (OR = 1.030; 95% CI = 1.008-1.052; p = 0.008) was independently associated with the development of SDG in patients with bilateral DC. In the multivariate analysis, SDG in patients without DC was not associated with the development of hydrocephalus. However, SDG was significantly associated with the development of hydrocephalus for patients who underwent DC (OR = 2.173; 95% CI = 1.362-3.467; p = 0.001). CONCLUSIONS: This study suggested that the incidence of SDG in patients who have and have not undergone DC was identical; however, the patients' characteristics and risk factors differed. Therefore, the management and prediction of SDG should be performed according to SDG type.

Consensus-based recommendations for diagnosis and surgical management of cranioplasty and post-traumatic hydrocephalus from a European panel.

Introduction: Planning cranioplasty (CPL) in patients with suspected or proven post-traumatic hydrocephalus (PTH) poses a significant management challenge due to a lack of clear guidance. Research question: This project aims to create a European document to improve adherence and adapt to local protocols based on available resources and national health systems. Methods: After a thorough non-systematic review, a steering committee (SC) formed a European expert panel (EP) for a two-round questionnaire using the Delphi method. The questionnaire employed a 9-point Likert scale to assess the appropriateness of statements inherent to two sections: "Diagnostic criteria for PTH" and "Surgical strategies for PTH and cranial reconstruction." Results: The panel reached a consensus on 29 statements. In the "Diagnostic criteria for PTH" section, five statements were deemed "appropriate" (consensus 74.2-90.3 %), two were labeled "inappropriate," and seven were marked as "uncertain."In the "Surgical strategies for PTH and cranial reconstruction" section, four statements were considered "appropriate" (consensus 74.2-90.4 %), six were "inappropriate," and five were "uncertain." Discussion and conclusion: Planning a cranioplasty alongside hydrocephalus remains a significant challenge in neurosurgery. Our consensus conference suggests that, in patients with cranial decompression and suspected hydrocephalus, the most suitable diagnostic approach involves a combination of evolving clinical conditions and neuroradiological imaging. The recommended management sequence prioritizes cranial reconstruction, with the option of a ventriculoperitoneal shunt when needed, preferably with a programmable valve. We strongly recommend to adopt local protocols based on expert consensus, such as this, to guide patient care.

Case Report of a Post-Traumatic Hydrocephalus Patient: Ventriculo-Vesicle Shunt With a Review of the Literature.

Post-traumatic hydrocephalus (PTH) is treated through cerebrospinal fluid (CSF) diversion, typically through ventriculoperitoneal shunt (VPS) or other bypass techniques. As these shunts are associated with significant complications and high revision rates in certain populations, it is important to tailor a patient's shunt procedure according to their medical history and complications. Herein, we report the case of a 30-year-old man with PTH following a traffic accident on a motorcycle. VPS was chosen as the method of treatment but required multiple revisions and replacements due to persistent complications such as post-operative infection, shunt obstruction and abdominal problem. As the patient's heart failure and pleural effusion rendered both ventriculopleural and ventriculoatrial shunt not feasible, it was decided to move the shunt to the bladder (ventriculo-vesicle shunt [VVS]) in cooperation with a urologist. Follow-up examinations after about 3 months showed a decrease in ventricle size, improved hydrocephalus, and no complications such as urinary infection or bladder stone formation. In cases where the patient's underlying conditions, such as heart failure and pleural effusion, make it unsuitable to choose the pleural cavity or atrium as non-peritoneal spaces, VVS can be a suitable option for continuous CSF drainage when complications have occurred with the previous VPS.

Middle Cerebral Artery Compromise Associated With Post-traumatic Hydrocephalus: A Case Report.

Post-traumatic hydrocephalus (PTH) is a commonly encountered complication following decompressive craniectomy, and is usually characterized by symptoms including headache, nausea, vomiting, and papilledema. Extracranial herniation accompanied by hemiplegia is a rare complication in patients with PTH who underwent craniectomy after subdural hematoma removal. We report a case of PTH that presented with extracranial herniation within one month of decompressive craniectomy. Following ventriculoperitoneal shunt implantation, left hemiplegia improved dramatically with restoration of the left middle cerebral artery blood flow, which was evident on serial imaging. Vascular compromise is often overshadowed by increased intracranial pressure when clinicians are dealing with traumatic brain injury patients. Delicate neurological and radiological examinations and prompt early interventions could lead to optimal outcomes in patients receiving decompressive craniectomy.