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.

Complicación tras craniectomía descompresiva: el «síndrome del paciente trepanado» de aparición precoz / Complication of descompressive craniectomy: An early «syndrome of the trephined»

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Giant skull base atypical meningioma presenting with rapidly progressive impaired consciousness caused by severe venous congestion: case report.

A 43-year-old female presented with a giant skull base atypical meningioma manifesting as rapid progression of impaired consciousness. The meningioma was located in the ethmoid sinus, sphenoid sinus, nasal cavity, and left middle temporal fossa, and the intracranial portion of the tumor involved the left temporal region with massive surrounding brain edema in the left temporal lobe and basal ganglia. She underwent emergent fronto-temporo-parietal decompressive craniectomy, and the intracranial portion of the tumor was resected to control intracranial pressure. She recovered consciousness and neurological function dramatically, and subsequently underwent radical tumor resection via combined extended transbasal and left lateral transzygomatic infratemporal fossa approaches one month after the initial surgery. The extensive brain edema completely disappeared after tumor resection, and the patient fully recovered without neurological deficits except anosmia and small visual field defect. Rapid neurological deterioration and disturbance of consciousness caused by extensive peritumoral brain swelling are unusual in meningioma. In this case, the extemporaneous decompressive craniectomy was highly useful in the management of increased intracranial pressure.

Does cranioplasty following decompressive craniectomy improve consciousness?

BACKGROUND: Cranioplasty (CP) following decompressive craniectomy (DC) is traditionally viewed as a cosmetic procedure having no effect on neurological function in most cases after severe brain injury. However, anecdotal cases of improvement in conscious level after CP have been observed in clinical practice. AIM: To investigate whether CP is associated with consistent change in level of consciousness. METHOD: Records of patients undergoing CP from January 2007 to January 2009 were retrospectively reviewed. Four measurements were taken between DC and CP and four following CP. Each measurement included total Glasgow Coma Scale (GCS), individual GCS components, pupil size and limb power. Pre- and post-CP values were compared. Data were collected and analysed using Microsoft Excel and SPSS. RESULTS: Twenty-three patients, 16 males, mean age 37 years (range 16-64), were studied. There was a significant improvement in GCS over time (p<0.01). To test the specific impact of CP, immediate pre- and post-CP GCS values were compared, assuming time-based improvement over this interval is minimal and improvement is attributable to CP. No significant change in immediate pre- and post-CP GCS was found. CONCLUSIONS FOR DISCUSSION: Improvement in consciousness attributable to CP has significant implications for clinical practice. This study found no evidence that CP has an effect on GCS in addition to expected time-based recovery. The results were limited by the sensitivity of the Glasgow Coma Scale.

[Effect of strong stimulation of acupuncture at twelve Jing-well points as main for neurosurgery patients with disorder of consciousness].

OBJECTIVE: To observe the promoting consciousness effect of acupuncture for neurosurgery patients with disorder of consciousness. METHODS: Ninety-two neurosurgery patients with medium or severe disorder of consciousness were randomly divided into an acupuncture plus medicine group and a western medicine group, 46 cases in each group. The acupuncture plus medicine group was treated with the routine western medicine and acupuncture with strong stimulation at twelve Jing points and Shuigou (GV 26) combined with electroacupuncture at Baihui (GV 20), Sishencong (EX-HN 1), Shenting (GV 24) and Benshen (GB 13). The western medicine group was treated by routine western medicine. Two courses later, the therapeutic effects were compared between the two groups. RESULTS: After treatment, the total effective rate was 100.0% in the acupuncture plus medicine group and 91.3% in the western medicine group, with a significant difference between the two groups (P<0.01). CONCLUSION: Strong stimulation of acupuncture at twelve Jing points and Shuigou (GV 26) combined with electroacupuncture at the head acupoints have an obvious promotion of consciousness recovery for neurosurgery patients with disturbance of consciousness, and acupuncture involved in the treatment can significantly shorten the healing time.

The role of the trauma nurse leader in a pediatric trauma center.

The trauma nurse leader role was developed by a group of trauma surgeons, hospital administrators, and emergency department and trauma leaders at Nationwide Children's Hospital who recognized the need for the development of a core group of nurses who provided expert trauma care. The intent was to provide an experienced group of nurses who could identify and resolve issues in the trauma room. Through increased education, exposure, mentoring, and professional development, the trauma nurse leader role has become an essential part of the specialized pediatric trauma care provided at Nationwide Children's Hospital.

Can midline brain shift be used as a prognostic factor to predict postoperative restoration of consciousness in patients with chronic subdural hematoma?

BACKGROUND AND PURPOSE: Our aim was to determine if midline brain shift could be used as a prognostic factor to predict postoperative restoration of consciousness in patients with CSDH. In these patients, we evaluated the relation (1) between midline brain shift as measured on CT and alteration of level of consciousness, and (2) between midline brain shift and restoration of consciousness after the operation. METHODS: Prospectively recorded data of 45 patients with CSDH were evaluated. We compared level of consciousness of patients measured by GCS score, brain displacement at PG and SP both in the preoperative and early postoperative period. RESULTS: Preoperatively, PG and SP shifts of the patients who were alert (GCS = 15) were significantly less than those of patients who had diminished consciousness. However, in patients with diminished consciousness (GCS < 15), the amount of lateral brain displacement and the degree of diminution of consciousness did not correlate. Those patients who had a preoperative SP shift of less than 10 mm had a significantly lesser chance to become alert after operation (2 of 5 patients) when compared with those patients who had a preoperative SP shift of 10 mm or more (21 of 23 patients). CONCLUSIONS: We conclude that preoperative SP shift may be used as a factor to predict restoration of consciousness in patients with CSDH; the likelihood of becoming alert after operation is increased if SP shift is 10 mm or greater, and is decreased if SP shift is less than 10 mm.

Early surgery for brainstem cavernomas.

BACKGROUND: The purpose was to review our experience with the surgical management of brainstem cavernomas (BSCs) and especially the impact of the surgical timing on the clinical outcome. METHOD: We retrospectively reviewed 22 patients harboring a BSC, who underwent 23 procedures. FINDINGS: Surgery was carried out during the early stage after the last haemorrhage, with a mean delay of 21.6 days (range 4-90 days). Sixteen procedures were performed after a first bleeding event while seven after multiple bleedings. Complete resection was achieved in 19 patients (86.4%). Early after surgery, 12 patients (52.2%) improved neurologically, 5 (21.7%) were stable and 6 (26.1%) worsened. New postoperative deficits were noted after 9 procedures (39.1%). Statistically significant factors for postoperative aggravation were: late surgery (P = 0.046) and multiple bleedings (P = 0.043). No patient operated on within the first 19 days after bleeding did worsen (n = 11), as opposed to 6 out of 12 who did when operated on later. After a mean follow-up of 44.9 months, 20 patients (90.9%) were improved, 1 patient (4.6%) was worse and 1 patient was lost to follow-up (4.6%), after reoperation for rebleeding of a previously completely resected cavernoma. Late morbidity was reduced to 8.6%. The mean Glasgow Outcome Scale (GOS) at the end of the follow-up period was 4.24, compared to a mean preoperative GOS of 3.22 (P<0.001). Complete neurological recovery of motor deficits, sensory disturbances, cranial nerves (CNs), internuclear ophtalmoplegia and cerebellar dysfunction were respectively 41.7%, 38.5%, 52.6%, 60.0% and 58.3%. Among the most affected CNs: CN 3, CN 5 and CN 7 were more prone to completely recover, respectively in 60.0%, 70.0% and 69.2%. CONCLUSIONS: Surgical removal of BSCs is feasible in experienced hands with acceptable morbidity and good outcome. Early surgery and single bleeding were associated with better surgical results.

EEG changes during awake carotid endarterectomy.

To determine the reason for differing shunt rates based on electroencephalographic (EEG) and neurologic changes during general and regional anesthetic, respectively, we compared simultaneous EEG tracings and neurologic status in 135 patients undergoing carotid endarterectomy (CEA) under cervical block over a 30-month period. The decision to shunt in these patients was made on the basis of neurologic changes only irrespective of EEG findings. This group was then compared to the 288 patients undergoing CEA under general anesthetic with EEG monitoring over the same period. EEG changes occurred in 7.4% of awake patients and 15.3% of asleep patients (p < 0.03). The rates of ipsilateral hemispheric changes were similar, but no awake patient manifested global EEG changes with clamping while 3.5% of patients under general anesthesia did (p < 0.04). Global, but not hemispheric, changes were correlated with systolic blood pressure variability during clamping. This implies that global EEG changes in anesthetized patients may be the result of the anesthetic technique itself, and that cervical block may in fact be cerebroprotective.

[A clinical study of posttraumatic hydrocephalus].

From 1989 to 1998, 721 patients with head injury were admitted to our department and 22 (3.1%) of them developed posttraumatic hydrocephalus. These patients included 16 males and 6 females, ranging in age from 17 to 86 years (mean age, 66 yrs) with peak incidence in the eighth decade. CT scan on admission immediately after head injury showed subarachnoid hemorrhage (SAH) in 18 cases. The other 4 cases without SAH had once suffered head injuries severe enough to give rise to consciousness disturbance. The typical clinical symptoms of hydrocephalus were observed in only 5 (23%) patients, and in the other 17 cases prolonged or deteriorated of consciousness disturbance were the main symptoms. Hydrocephalus was diagnosed between 1 and 3 months in 15 cases and in 7 cases after 4 months. Clinical improvement has been seen in 17 (77%) cases and marked recovery of consciousness was achieved in 12 cases after V-P shunt, but 5 cases with severe disturbance of consciousness revealed no improvement of clinical signs even after decrease of ventricular size. These results indicate that elderly patients with traumatic SAH should be followed up for at least 4 to 5 months, paying attention to development of hydrocephalus, and V-P shunt would be effective to improve consciousness disturbance in most of the cases.

A prospective population-based study of pediatric trauma patients with mild alterations in consciousness (Glasgow Coma Scale score of 13-14).

OBJECTIVE: Considerable controversy surrounds the appropriate evaluation of children with mild alterations in consciousness after closed head trauma (Glasgow Coma Scale [GCS] score of 13-14). The objective of the current study was to determine the incidence of intracranial lesions in pediatric patients with a field GCS score of 13 or 14 after closed head injuries. METHODS: The current study is a population-based, multicenter prospective study of all patients to whom emergency medical services responded during a 12-month period. The setting was urban Los Angeles County, encompassing a patient population of 2.3 million children, 13 designated trauma centers, and 94 receiving hospitals. RESULTS: In the pediatric age group (<15 yr old), 8488 patients were transported by emergency medical services for injuries. Of these, 209 had a documented field GCS score of 13 or 14. One hundred fifty-seven patients were taken to trauma centers, and 135 (86%) underwent computed tomography. Forty-three patients (27.4%) had abnormal results on computed tomographic scans, 30 (19.1%) had an intracranial hemorrhage, and 5 required an operative neurosurgical procedure for hematoma evacuation. Positive and negative predictive values of deteriorating mental status (0.500 and 0.844, respectively), loss of consciousness (0.173 and 0.809), cranial fracture (0.483 and 0.875, and extracranial injuries (0.205 and 0.814) were poor predictors of intracranial hemorrhage. CONCLUSION: Pediatric patients who have mild alterations in consciousness in the field have a significant incidence of intracranial injury. The great majority of these patients will not require operative intervention, but the implications of missing these hemorrhages can be severe for this subgroup of head-injured patients. Because clinical criteria and cranial x-rays are poor predictors of intracranial hemorrhage, it is recommended that all children with a GCS score of 13 or 14 routinely undergo screening via non-contrast-enhanced computed tomography.