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1.
Rozhl Chir ; 99(7): 316-322, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32972150

RESUMO

INTRODUCTION: Decompressive craniectomy is an important method for managing refractory intracranial hypertension. Although decompressive craniectomy is a relatively simple procedure, various complications may arise. The aim of our paper was to determine the incidence of complications of decompressive craniectomy in patients with head injury and to analyse their risk factors. METHODS: We retrospectively analysed a group of 94 patients after decompressive craniectomy for head injury between 01 Jan 2014 and 31 Dec 2018. Postoperative complications were evaluated based on clinical examination and postoperative CT scan. The impact of potential risk factors on the occurrence of complications was assessed (age, worse initial clinical condition, any haemocoagulation disorder). RESULTS: Twenty patients died within the first month after surgery. Control CT scan showed one complication in 78 patients (83%), while 46 patients (49%) had more than one complication. We had to reoperate 22 patients (23.4%) due to a complication. The following complications were found: postoperative acute subgaleal/subdural haematoma (30× - 32%), subgaleal/subdural cerebrospinal fluid effusion (29× - 31%), soft tissues oedema (29× - 31%), haemorrhagic progression of brain contusion (17× - 18%), malignant brain oedema (8× - 8.5%), hydrocephalus (8× - 8.5%), temporal muscle atrophy (7× - 7.5%), peroperative massive bleeding ( 6× - 6.4%), epilepsy (4× - 4.3%), syndrome of the trephined (2× - 2.1%), skin necrosis (2× - 2.1%). Patients with a haemocoagulation disorder had a significantly higher incidence of complications (p=0.01). CONCLUSION: Complications of decompressive craniectomy after head injury are frequent. The potential benefit of decompressive craniectomy can be adversely affected by the occurrence of many complications.


Assuntos
Lesões Encefálicas , Traumatismos Craniocerebrais/complicações , Traumatismos Craniocerebrais/cirurgia , Craniectomia Descompressiva/efeitos adversos , Derrame Subdural/cirurgia , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento
2.
Stroke ; 51(9): e215-e218, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32639861

RESUMO

BACKGROUND AND PURPOSE: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.


Assuntos
Isquemia Encefálica/complicações , Isquemia Encefálica/cirurgia , Infecções por Coronavirus/complicações , Craniectomia Descompressiva/métodos , Procedimentos Neurocirúrgicos/métodos , Pneumonia Viral/complicações , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/cirurgia , Adulto , Edema Encefálico/complicações , Edema Encefálico/cirurgia , Isquemia Encefálica/diagnóstico por imagem , Causas de Morte , Tomada de Decisão Clínica , Cuidados Críticos , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Procedimentos Neurocirúrgicos/efeitos adversos , Pandemias , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do Tratamento
3.
J Clin Neurosci ; 78: 273-276, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32402617

RESUMO

Subdural hygroma (SDG) represents a common complication following decompressive craniectomy (DC). To our knowledge we present the first meta-analysis investigating the role of clinical and technical factors in the development of SDG after DC for traumatic brain injury. We further investigated the impact of SDG on the final prognosis of patients. The systematic review of the literature was done according to the PRISMA guidelines. Two different online medical databases (PubMed/Medline and Scopus) were screened. Four articles were included in this meta-analysis. Data regarding age, sex, trauma dynamic, Glasgow Coma Scale (GCS), pupil reactivity and CT scan findings on admission were collected for meta-analysis in order to evaluate the possible role in the SDG formation. Moreover we studied the possible impact of SDG on the outcome by evaluating the rate of patients dead at final follow-up and the Glasgow Outcome Scale (GOS) at final follow-up. Among the factors available for meta-analysis only the basal cistern involvement on CT scan was associated with the development of a SDG after DC (p < 0.001). Moreover, patients without SDG had a statistically significant better outcome compared with patients who developed SDG after DC in terms of GOS (p < 0.001). The rate of patients dead at follow-up was lower in the group of patients without SDH (8.25%) compared with patients who developed SDG (11.51%). SDG after DC is a serious complication affecting the prognosis of patients. Further studies are needed to define the role of some adjustable technical aspect of DC in preventing such a complication.


Assuntos
Lesões Encefálicas Traumáticas/diagnóstico por imagem , Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/efeitos adversos , Craniectomia Descompressiva/tendências , Complicações Pós-Operatórias/diagnóstico por imagem , Derrame Subdural/diagnóstico por imagem , Escala de Coma de Glasgow/tendências , Escala de Resultado de Glasgow/tendências , Humanos , Complicações Pós-Operatórias/etiologia , Derrame Subdural/etiologia , Tomografia Computadorizada por Raios X/tendências
4.
PLoS One ; 15(4): e0232631, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32353054

RESUMO

BACKGROUND AND PURPOSE: Posttraumatic hydrocephalus affects 11.9%-36% of patients undergoing decompressive craniectomy (DC) after traumatic brain injury and necessitates a ventriculo-peritoneal shunt placement. As bone and arachnoid trabeculae share the same collagen type, we investigated possible connections between the skull Hounsfield unit (HU) values and shunt-dependent hydrocephalus (SDHC) in patients that received cranioplasty after DC for traumatic acute subdural hematoma (SDH). METHODS: We measured HU values in the frontal bone and internal occipital protuberance from admission brain CT. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off skull HU values for predicting SDHC in patients receiving cranioplasty after DC due to traumatic acute SDH. We investigated independent predictive factors for SDHC occurrence using multivariable logistic regression analysis. RESULTS: A total of 162 patients (>15 years of age) were enrolled in the study over an 11-year period from two university hospitals. Multivariable logistic analysis revealed that the group with simultaneous frontal skull HU ≤797.4 and internal occipital protuberance HU ≤586.5 (odds ratio, 8.57; 95% CI, 3.05 to 24.10; P<0.001) was the only independent predictive factor for SDHC in patients who received cranioplasty after DC for traumatic acute SDH. CONCLUSIONS: Our study reveals a potential relationship between possible low bone mineral density and development of SDHC in traumatic acute SDH patients who had undergone DC. Our findings provide deeper insight into the association between low bone mineral density and hydrocephalus after DC for traumatic acute SDH.


Assuntos
Craniectomia Descompressiva/efeitos adversos , Hematoma Subdural Agudo/cirurgia , Hidrocefalia/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Crânio/diagnóstico por imagem , Adulto , Idoso , Feminino , Seguimentos , Hematoma Subdural Agudo/diagnóstico por imagem , Humanos , Hidrocefalia/etiologia , Hidrocefalia/cirurgia , Processamento de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Período Pré-Operatório , Estudos Retrospectivos , Medição de Risco/métodos , Tomografia Computadorizada por Raios X , Derivação Ventriculoperitoneal/estatística & dados numéricos
5.
J Clin Neurosci ; 77: 213-217, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32409216

RESUMO

Sinking skin flap syndrome (SSFS) is a complication among long-term survivors of stroke or traumatic brain injury treated by decompressive craniectomy. The syndrome encompasses a wide spectrum of neurological symptoms including cognitive decline, seizures, speech and sensorimotor deficits. Early cranioplasty appears to improve cerebral perfusion, but the efficacy of cranioplasty in neurocognitive outcome in long-standing SSFS patient is unclear. We report a 64-year-old patient who suffered from traumatic brain injury and underwent decompressive craniectomy 18 years ago. She had chronic SSFS with pre-cranioplasty assessments demonstrating severe neurocognitive impairments which were static over time. After cranioplasty with custom-made polyetheretherketone flap to restore the 264 cm2 skull defect, magnetic resonance perfusion scan with pseudo-continuous arterial spin labelling technique showed a two-fold augmentation of cerebral blood flow in both frontal lobes, as well as areas distal to the sunken skin flap compared to baseline. This is accompanied by improvement of neurocognitive function as assessed by Montreal Cognitive Assessment, Neurobehavioral Cognitive State Examination, and Rivermead Behavioural Memory Test three and six months after cranioplasty. The patient's quality of life and that of her primary carer also showed improvement. This report describes a case of neurocognitive and global cerebral perfusion improvement after cranioplasty in the setting of prolonged SFSS of 18 years, and adds to the growing body of literature supporting the therapeutic role of cranioplasty beyond purely protective or cosmetic indications. The advantages and clinical utility of pCASL MR perfusion in assessing serial CBF before and after cranioplasty is illustrated.


Assuntos
Disfunção Cognitiva/etiologia , Craniectomia Descompressiva/efeitos adversos , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Retalhos Cirúrgicos/efeitos adversos , Lesões Encefálicas Traumáticas/cirurgia , Circulação Cerebrovascular/fisiologia , Disfunção Cognitiva/cirurgia , Craniectomia Descompressiva/métodos , Feminino , Humanos , Angiografia por Ressonância Magnética/métodos , Espectroscopia de Ressonância Magnética/métodos , Pessoa de Meia-Idade , Imagem de Perfusão/métodos , Complicações Pós-Operatórias/etiologia , Qualidade de Vida , Recuperação de Função Fisiológica , Crânio/cirurgia , Síndrome
6.
Rozhl Chir ; 99(1): 5-14, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32122134

RESUMO

Through the decades of its use in the management of neurosurgical emergencies decompressive craniectomy has found its place as a life-saving procedure capable of a radical reduction of the intracranial pressure. Clinical results and rate of survival after decompressive craniectomy vary according to the primary diagnosis, and they have been a subject of multicentric randomized trials. However,  considerable attention also needs to be kept on complications associated with the craniectomy. They are based not only on the procedures invasivity but also on the pathophysiological changes associated with a conversion of the closed intracranial space to an open one. The complications may further disturb the postoperative care and convalescence in the surviving patients, and therefore in the salvageable patients the indication of decompressive craniectomy should be based on information about the expected outcome and complications rate, at the same moment prevention, early recognition and adequate therapy of the complications should be emphasized. This work describes the most common complications occurring in patients after decompressive craniectomy, their pathophysiological principles and means of treatment and prevention.


Assuntos
Lesões Encefálicas , Craniectomia Descompressiva/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos , Humanos , Pressão Intracraniana , Complicações Pós-Operatórias , Resultado do Tratamento
7.
J Neurol Surg A Cent Eur Neurosurg ; 81(4): 297-301, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32126574

RESUMO

BACKGROUND: The purpose of the study was to evaluate the impact of craniotomy (CO) and decompressive craniectomy (DC) for evacuation of acute subdural hematoma (SDH) on pulmonary complications and sepsis. METHODS: Study data were obtained from the National Trauma Data Bank (2007-2010). Only patients who met all of the following criteria were included in this analysis: sustained blunt injuries, presented with severe traumatic brain injury, sustained an associated SDH, presented with an initial Glasgow Coma Scale (GCS) score ≤ 8 and an Abbreviated Injury Scale score of head ≥ 3, and underwent a CO or DC within 4 hours of hospital arrival. Patient characteristics and outcomes were compared between CO and DC, the two procedural groups. The data were first compared between the two unmatched groups; then propensity score matching and a matched pairs analysis were performed. RESULTS: From the total population of 2,370 patients, 1,852 (78%) of them underwent CO, and the remaining 518 (22%) underwent DC. Some differences were found between the CO and DC groups regarding age (mean [standard deviation (SD)]: 47.9 years [22.8] versus 39.6 years [20.1]; p < 0.001), sex (male: 70.1% versus 74.7%; p = 0.05), race (white: 77.4% versus 73.4%; p = 0.06), the injury mechanism (fall: 50.7% versus 33.2%; p < 0.001), Injury Severity Score (mean [SD]: 28.0 [9.3] versus 30.5 [10.0]; p < 0.001), and GCS score (median [interquartile range] 3 [3-5] versus 3 [3-4])). After the propensity score matching, no significant differences were found between the groups on the variables just listed (all p > 0.05). No significant differences were seen between the CO and DC groups in the incidences of these conditions: acute respiratory distress syndrome (ARDS) (12.0% versus 8.1%; p = 0.20), pneumonia (34.9% versus 37.6%; p = 0.60), pulmonary embolism (PE) (3.5% versus 1.6%; p = 0.30), and systemic sepsis (6.2% versus 8.1%; p = 0.5). CONCLUSION: Although most of the patients underwent CO for acute SDH, no significant differences were observed in the incidence of ARDS, pneumonia, PE, or systemic sepsis when compared with patients who underwent DC.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniotomia/efeitos adversos , Craniectomia Descompressiva/efeitos adversos , Hematoma Subdural Agudo/cirurgia , Pneumonia/etiologia , Embolia Pulmonar/etiologia , Sepse/etiologia , Adulto , Idoso , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
8.
Plast Reconstr Surg ; 145(6): 1486-1494, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32195855

RESUMO

BACKGROUND: Large decompressive craniectomies may be life-saving; however, they may also result in syndrome of the trephined. This postrecovery sequela is characterized by dizziness, fatigue, depression, weakness, speech slowing, gait disturbance, and impaired mentation. Because this entity is poorly understood, the authors attempted to quantify the functional improvement in patients with syndrome of the trephined after cranial vault reconstruction. METHODS: Patients with cranial vault defects (>50 cm) from trauma, meningioma, and hemorrhage were studied preoperatively and postoperatively (6 months) after cranial vault reconstruction using (1) the Cognistat Active Form and (2) the Functional Independence Measure instrument (n = 40). Cranial vault reconstructive techniques varied from split cranial bone to alloplastic implants (polyetheretherketone or titanium mesh). RESULTS: Of the 143 patients treated with decompressive craniectomies, 28 percent (n = 40) developed symptoms of syndrome of the trephined. A larger craniectomy defect size correlated with development of syndrome of the trephined. Time from craniectomy to presentation of symptoms was 4.5 months. Time from craniectomy to cranial vault reconstruction was 6.1 months. Time from cranial vault reconstruction to symptom improvement was 4.3 days. Complete functional recovery of syndrome of the trephined was seen in 70 percent. Type of cranial vault reconstruction included polyetheretherketone implant (57.5 percent), split calvarial graft (22.5 percent), and titanium mesh (20 percent), and was not a determinant of functional improvement. Cognistat assessment score noted improvement (from 38 to 69); likewise, the Functional Independence Measure measurement tool showed improvement (from 38 to 98). CONCLUSIONS: Syndrome of the trephined occurs more frequently than previously described in posttraumatic patients with large cranial vault defects. Cranial vault reconstruction leads to significant, quantifiable functional improvement in a large number of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Craniectomia Descompressiva/efeitos adversos , Doenças do Sistema Nervoso/cirurgia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Trepanação/efeitos adversos , Adulto , Placas Ósseas , Transplante Ósseo , Feminino , Humanos , Cetonas , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/diagnóstico , Doenças do Sistema Nervoso/etiologia , Polietilenoglicóis , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Reconstrutivos/instrumentação , Estudos Retrospectivos , Crânio/cirurgia , Síndrome , Titânio , Resultado do Tratamento
9.
World Neurosurg ; 138: 313-316, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32217177

RESUMO

BACKGROUND: Autologous bone resorption is a frequent complication of cranioplasty, often necessitating reoperation. The etiology of this phenomenon is unknown, although it has recently been associated with indolent Propionibacterium acnes infection. CASE DESCRIPTION: A 59-year-old man initially presented with a traumatic acute subdural hematoma treated with emergent decompressive hemicraniectomy and hematoma evacuation. His bone flap was cryopreserved. He underwent cranioplasty with autologous bone 3 months later. Over the subsequent 14 months, serial imaging demonstrated progressive bone flap resorption, ultimately requiring repeat cranioplasty with a custom allograft. Although there was no evidence of infection at the time of repeat cranioplasty, routine culture swabs were taken and grew P. acnes after the patient had been discharged home. Pathologic analysis of the fragments of the original bone flap that were removed demonstrated osteonecrosis with marrow fibrosis but no evidence of inflammation or infection. He was treated with 6 weeks of intravenous antibiotics and had no evidence of infection at 8-month follow-up. CONCLUSIONS: Indolent P. acnes infection can precipitate autologous bone flap resorption. While the mechanism of this is unknown, pathologic analysis of a partially resorbed bone flap in the setting of an indolent P. acnes infection found no evidence of an infectious process or inflammation within the bone. Further studies are needed to elucidate the mechanism of action of P. acnes in bone flap resorption.


Assuntos
Reabsorção Óssea/microbiologia , Craniectomia Descompressiva/efeitos adversos , Infecções por Bactérias Gram-Positivas/complicações , Retalhos Cirúrgicos/microbiologia , Infecção da Ferida Cirúrgica/microbiologia , Humanos , Masculino , Pessoa de Meia-Idade , Propionibacterium acnes
10.
World Neurosurg ; 137: e517-e525, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32081819

RESUMO

BACKGROUND: In the presence of a skull deformity after large decompressive craniectomy (DC), neurologic deterioration manifesting as epileptic syndrome (ES) may occur independently of the primary disease or spontaneous improvement may be unduly impaired, and these unfavorable outcomes have sometimes been reversed by cranioplasty. The objective of this study was to analyze the influence of cranioplasty on the presence of ES in patients who underwent DC. METHODS: A prospective study was performed from October 2016 to October 2017 involving patients who underwent DC and subsequent cranioplasty. Electroencephalographic (EEG) status before and after cranioplasty was analyzed in the presence of seizures and was compared with results after DC. RESULTS: The sample included 52 patients. Male sex (78.8%) and traumatic brain injury (82.7%) were common indications for DC. ES after DC was verified in 26.9% of patients, and 50% of patients presented with abnormal EEG status. ES after cranioplasty was noted in 21.2% and 36.3% of patients followed by abnormal EEG status. All patients with precranioplasty epileptogenic paroxysms showed better EEG tracings after the procedure. CONCLUSIONS: In routine clinical practice, altered amplitudes were observed in the region of bone defects. Although cranioplasty reduced pathologic EEG status (epileptogenic paroxysms), it was not able to produce new EEG tracings that could predict changes in seizure discharge or reduce ES.


Assuntos
Craniectomia Descompressiva/efeitos adversos , Síndromes Epilépticas/cirurgia , Complicações Pós-Operatórias/cirurgia , Convulsões/cirurgia , Crânio/cirurgia , Adulto , Lesões Encefálicas Traumáticas/cirurgia , Eletroencefalografia , Síndromes Epilépticas/etiologia , Síndromes Epilépticas/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Defeitos do Tubo Neural , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Procedimentos Cirúrgicos Reconstrutivos , Convulsões/etiologia , Convulsões/fisiopatologia , Resultado do Tratamento , Adulto Jovem
11.
Acta Neurochir (Wien) ; 162(4): 745-753, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32025876

RESUMO

BACKGROUND: Secondary cranioplasty (CP) is considered to support the neurological recovery of patients after decompressive craniectomy (DC), but the treatment success might be limited by complications associated to confounders, which are not yet fully characterized. The aim of this study was to identify the most relevant factors based on the necessity to perform revision surgeries. METHODS: Data from 156 patients who received secondary CP following DC for severe traumatic brain injury (TBI) between 1984 and 2015 have been retrospectively analyzed and arranged into cohorts according to the occurrence of complications requiring surgical intervention. RESULTS: Cox regression analysis revealed a lower revision rate in patients with polymethylmethacrylate (PMMA) implants than in patients with autologous calvarial bone (ACB) implants (HR 0.2, 95% CI 0.1 to 1.0, p = 0.04). A similar effect could be observed in the population of patients aged between 18 and 65 years, who had a lower risk to suffer complications requiring surgical treatment than individuals aged under 18 or over 65 years (HR 0.4, 95% CI 0.2 to 0.9, p = 0.02). Revision rates were not influenced by the gender (p = 0.88), timing of the CP (p = 0.53), the severity of the TBI (p = 0.86), or the size of the cranial defect (p = 0.16). CONCLUSIONS: In this study, the implant material and patient age were identified as the most relevant parameters independently predicting the long-term outcome of secondary CP. The use of PMMA was associated with lower revision rates than ACB and might provide a therapeutic benefit for selected patients with traumatic cranial defects.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/métodos , Próteses e Implantes , Adolescente , Adulto , Fatores Etários , Idoso , Materiais Biocompatíveis , Transplante Ósseo/métodos , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polimetil Metacrilato , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Prognóstico , Procedimentos Cirúrgicos Reconstrutivos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
12.
Acta Neurochir (Wien) ; 162(3): 469-479, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32016585

RESUMO

OBJECTIVE: To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI). METHODS: A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, "primary procedure" and "secondary procedure", was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO2) values as well as the need for additional osmotherapy and CSF drainage. RESULTS: Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average post-surgical ICP values, higher PbO2 values and required less osmotic treatments as compared with those treated with DC alone. CONCLUSION: Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/métodos , Complicações Pós-Operatórias/epidemiologia , Ventriculostomia/métodos , Adulto , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Pressão Intracraniana , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio , Complicações Pós-Operatórias/prevenção & controle , Ventriculostomia/efeitos adversos
13.
World Neurosurg ; 136: e690-e694, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32006735

RESUMO

OBJECTIVE: The risk for developing posttraumatic hydrocephalus (PTH) is higher when patients undergo decompressive craniectomy as part of their treatment. The purpose of this study is to determine the prevalence of PTH after decompressive craniectomy in pediatric patients and determine associated risk factors that may lead to PTH. METHODS: A retrospective analysis was conducted by searching the Puerto Rico neurologic surgery database from 2010 to 2019. All pediatric patients (1-18 years old) at the University Pediatric Hospital of the Puerto Rico Medical Center who had traumatic brain injury and had a decompressive craniectomy were included in the study. Data were reviewed to determine if time to decompressive craniectomy, side of decompressive craniectomy, gender, mechanism of trauma, amount of subarachnoid hemorrhage, and time to cranioplasty were risk factors for the development of PTH. RESULTS: Incidence of PTH after decompressive craniectomy was 21%. Neither gender, side of decompressive craniectomy, mechanism of trauma, amount of subarachnoid hemorrhage, time from trauma to decompressive craniectomy, nor cranioplasty intervention had statistical significance for developing PTH. Time from decompressive craniectomy to cranioplasty was significant for development of PTH. CONCLUSIONS: Longer time to cranioplasty was associated with an increased likelihood of PTH. We recommend performing cranioplasty as soon as possible to reduce hydrocephalus development.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Craniectomia Descompressiva/efeitos adversos , Hidrocefalia/etiologia , Adolescente , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Criança , Pré-Escolar , Feminino , Humanos , Hidrocefalia/diagnóstico por imagem , Lactente , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios X
14.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 31(1): 7-13, ene.-feb. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-190367

RESUMO

OBJETIVO: El pronóstico en los infartos malignos de un hemisferio siembra dudas entre los neurocirujanos a la hora de indicar una hemicraniectomía descompresiva. ¿Qué resultados a corto y medio plazo se obtienen? ¿Están las familias satisfechas con la cirugía una vez el enfermo se encuentra en su domicilio? En el presente trabajo analizamos nuestra experiencia en esta materia en los últimos 13 años. MATERIAL Y MÉTODOS: Incluimos en nuestra revisión a 21 pacientes intervenidos entre 2004 y 2017 siguiendo la vía clínica de nuestro centro para el ictus. Se entrevistó a los familiares vía telefónica. Se midió el resultado funcional al alta, 3 meses, un año y actual con la escala modificada de Rankin (mRS). RESULTADOS: La edad demostró estar directamente relacionada con la mRS (r = 0,56; p = 0,035) y en el 37,5% se obtuvo un buen resultado (mRS ≤ 3). El 78,9% de los familiares entrevistados repetirían la decisión quirúrgica tomada. CONCLUSIONES: Aportamos un grupo de 21 pacientes intervenidos mediante craniectomía descompresiva por infarto maligno donde los mejores resultados funcionales se han dado entre los < 60 años. Las graves secuelas neurológicas en pacientes con infarto maligno intervenidos mediante hemicraniectomía descompresiva fueron toleradas y aceptadas por la mayoría de familias a favor de su supervivencia. No debemos dejar que esta satisfacción familiar camufle el pronóstico, teniendo que contextualizarla dentro de la situación real ambulatoria de los pacientes


OBJECTIVE: The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years. MATERIAL AND METHODS: In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS). RESULTS: Patient age was shown to be directly related to the mRS (r = 0.56; p = 0.035) and 37.5% achieved a good outcome (mRS ≤ 3); 78.9% of the interviewed relatives would repeat the surgical decision. CONCLUSIONS: We present a 21 patients group where the best outcome was achieved in patients ≤ 60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Infarto da Artéria Cerebral Média/epidemiologia , Percepção , Família , Craniectomia Descompressiva/efeitos adversos , Craniectomia Descompressiva/métodos , Infarto da Artéria Cerebral Média/cirurgia , Prognóstico , Inquéritos e Questionários , Estatísticas de Sequelas e Incapacidade , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Taxa de Sobrevida , Satisfação do Paciente
15.
J Clin Neurosci ; 73: 85-88, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31987632

RESUMO

BACKGROUND: In severe traumatic brain injury (TBI) patients undergoing decompressive hemicraniectomy (DHC), the rate of post-traumatic hydrocephalus (PTH) is high at 12-36%. Early diagnosis and shunt placement can improve outcomes. Herein, we examined the incidence of and predictors of PTH after craniectomy. METHODS: A retrospective analysis of prospectively collected database of severe TBI patients at a single U.S. Level 1 trauma center from May 2000 to July 2014 was performed. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), bleeding pattern and time-to-cranioplasty were analyzed. Glasgow Outcome Scale (GOS) scores at 6 and 12-months were studied. Statistical significance was assessed at p < 0.05. RESULTS: A total of 402 patients were enrolled and 105 patients had DHC. Twenty-two (21.0%) of 105 required ventriculoperitoneal shunt (VPS), compared to 18 (6%) of 297 patients without DHC. There was increased odds ratio for shunting after DHC at 3.62 (95%CI:1.62-8.07; p < 0.01). Mean age at time of DHC was 43.8 ± 17.7 years old, and 81.9% were male. Subdural hematoma (SDH) was most common at 57.1%. Median time from admission to cranioplasty was 63 days. Patients who experienced PTH after DHC were younger (35.5 ± 17.7 versus 46.0 ± 17.7 years, p < 0.01) and had higher ISS scores (35 versus 26, p = 0.04) compared to patients without shunt after DHC. CONCLUSIONS: After severe TBI requiring hemicraniectomy, shunt-dependent hydrocephalus was 21%. Younger patients and higher ISS score were associated with PTH. Shunt-dependent patients achieved similar 6- and 12-month outcomes as those without PTH. Early diagnosis and shunt placement can enhance long-term neurological recovery.


Assuntos
Craniectomia Descompressiva/efeitos adversos , Hidrocefalia/epidemiologia , Hidrocefalia/cirurgia , Adulto , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/epidemiologia , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Humanos , Hidrocefalia/patologia , Incidência , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Derivação Ventriculoperitoneal
16.
World Neurosurg ; 136: e294-e299, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31899408

RESUMO

OBJECTIVE: Recurrent subdural hematoma (SDH) is commonly encountered in clinical practice. Multiple surgical techniques have been reported for management of recurrent SDH with variable success and complication rates. We report an alternative technique to halt SDH reaccumulation in elderly patients with multiple recurrences despite multiple surgical evacuations via rescue craniectomy and subsequent cranioplasty. METHODS: We retrospectively identified all symptomatic recurrent SDHs in elderly patients (≥60 years old) who were surgically managed with rescue craniectomy with subsequent cranioplasty from November 2004 to January 2018. Patients' demographics and radiologic and surgical variables were recorded and analyzed. RESULTS: Of 287 patients who received surgical treatment for SDH, 19 patients (6.6%) underwent SDH evacuation with rescue craniectomy and subsequent cranioplasty were included in the study. The median age of the cohort was 73 years (interquartile range: 62-78 years), with 13 men and 6 women. Trauma was the cause of SDH in most cases. Five patients had acute SDH, 4 patients had subacute SDH, and 10 patients had chronic SDH. Fourteen patients had only 1 recurrence of SDH requiring surgical re-evacuation, and 5 had 2 recurrences. Median interval between craniectomy and cranioplasty was 64.5 days (interquartile range: 15-123.3 days). Four complications were encountered. After cranioplasty, 15 patients had no further hemorrhage or recurrence and 4 patients had stable subdural collection during an average follow-up of 38.2 ± 46.9 months. CONCLUSIONS: Rescue craniectomy followed by cranioplasty is a safe and effective salvage technique for the management of symptomatic recurrent SDH in elderly patients.


Assuntos
Craniectomia Descompressiva/métodos , Hematoma Subdural/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Idoso , Estudos de Coortes , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Recidiva , Estudos Retrospectivos , Crânio/cirurgia , Resultado do Tratamento
17.
J Neurol Surg A Cent Eur Neurosurg ; 81(3): 227-232, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31777050

RESUMO

BACKGROUND AND STUDY AIMS/OBJECTIVE: Cranioplasty, a common neurosurgical intervention following decompressive craniectomy (DC), is associated with high complication rates. Bone flap resorption in particular leads to a considerable number of patients requiring further surgery. The aim of this study was to investigate the frequency and time of occurrence of complications following cranioplastic procedures in children and adults. MATERIAL AND METHODS: Data of children and adults who underwent cranioplasty between July 2010 and March 2018 were analyzed retrospectively. Clinical data, complications, and risk factors regarding aseptic bone resorption (ABR) were evaluated including patient age, occurrence of shunt-dependent hydrocephalus, and number of fragments in autologous bone flaps. RESULTS: Severe traumatic brain injury (TBI) was the leading cause for DC among children (66.7%), associated with a significantly higher number of fragments (p = 0.002). In the adult population, the most common cause was malignant infarction (55.9%) followed by TBI (24.6%). Pediatric patients in our institution received autologous bone flaps less frequently than adult patients (61.1% and 83.1%, respectively). Young age and a higher number of fragments in autologous bone flaps were associated with the occurrence of ABR. Children and adolescents showed significantly higher rates of aseptic bone necrosis (p = 0.007) and revision cranioplasty (p = 0.036). Kaplan-Meier estimates were used to further analyze bone flap resorption in children and adults, showing that revision surgery due to ABR was performed earlier in children (p = 0.001, log-rank test). CONCLUSION: Pediatric patients demand specific care when cranioplasty is performed following DC. We identified age as an independent risk factor. The higher number of fragments appears to be a correlation due to the higher number of TBIs in children. Our data indicate that young age is the most important risk factor for the development of ABR as a frequent and early complication with a shorter revision-free time interval in children. Consequently, the uncritical use of cryopreserved autologous bone flaps should be questioned in this population.


Assuntos
Reabsorção Óssea/epidemiologia , Craniectomia Descompressiva/efeitos adversos , Osteonecrose/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Retalhos Cirúrgicos/efeitos adversos , Adolescente , Adulto , Fatores Etários , Idoso , Lesões Encefálicas Traumáticas/cirurgia , Criança , Pré-Escolar , Feminino , Humanos , Hidrocefalia/cirurgia , Lactente , Masculino , Pessoa de Meia-Idade , Próteses e Implantes , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Adulto Jovem
18.
J Craniofac Surg ; 31(2): 472-474, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31764555

RESUMO

Crainoplasty following decompressive craniotomy is widely applied clinically. Here, a 55-year-old male had clinical presentation of fever, headache, and ulceration at the anterior scalp of left ear, with 4 to 5 mL pus induction per day, where he accepted cranioplastic surgery 17 years ago using the material of medical silicone rubber. The results of experimental test and magnetic resonance imaging indicated a sign of infection. The authors reported a rarely delayed infection 17 years after cranioplastic surgery. The over long-term risks for the previously transplanted materials should be recognized.


Assuntos
Craniectomia Descompressiva/efeitos adversos , Infecções/complicações , Crânio/diagnóstico por imagem , Cefaleia/etiologia , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Crânio/cirurgia , Fatores de Tempo
19.
Turk Neurosurg ; 30(2): 225-230, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31608977

RESUMO

AIM: To evaluate the clinical characteristics of children who recently underwent decompressive craniectomy (DC) due to elevated intracranial pressure (ICP) correlated to head trauma or other causes, such as ischemic insult. MATERIAL AND METHODS: Twelve patients aged ≤17 years who underwent DC due to elevated ICP between 2013 and 2018 were included in the study. The clinical status of the participants, radiological characteristics, type and timing of surgery, and outcomes were recorded. RESULTS: Three female and nine male patients with a mean age of 10 years were included. The initial average Glasgow Coma Scale score was 6 (3-12). All patients presented with signs of diffuse cerebral edema and subdural hematoma of various sizes along with other intracranial pathologies. Only one patient required bilateral frontal craniectomy. In the postoperative period, three patients died, and three had severe disability. CONCLUSION: With the increasing use and success of DC in adults, this procedure can also be effective in children. Considering brain differences in children, large and well-structured clinical trials must be conducted to prevent complications and to identify the best technique, timing, and benefits of DC for children.


Assuntos
Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva , Hipertensão Intracraniana/cirurgia , Adolescente , Edema Encefálico/complicações , Edema Encefálico/fisiopatologia , Lesões Encefálicas Traumáticas/fisiopatologia , Criança , Craniectomia Descompressiva/efeitos adversos , Feminino , Hematoma Subdural/complicações , Hematoma Subdural/fisiopatologia , Hematoma Subdural/cirurgia , Humanos , Hipertensão Intracraniana/etiologia , Masculino , Estudos Retrospectivos , Resultado do Tratamento
20.
World Neurosurg ; 134: e298-e305, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31629151

RESUMO

OBJECTIVE: Primary decompressive craniectomy (DC) is an important therapeutic technique for severe head-injured patients with space-occupying lesions in emergency situations, but these patients are still at high risk for unfavorable outcomes. This study aimed to investigate the predictors of 30-day mortality in adult patients undergoing primary DC after traumatic brain injury (TBI). METHODS: All adult patients (≥18 years of age) who underwent primary DC from January 2012 to March 2019 were included. Demographic, clinical, surgical, and laboratory variables were collected for analysis. Early mortality was defined as 30-day mortality after DC. First, a univariate analysis (P < 0.05) was used to compare survivors and nonsurvivors. Multivariate logistic regression analysis was used to identify the predictors of 30-day mortality for patients who underwent primary DC. RESULTS: A total of 387 patients were enrolled in the study. The 30-day mortality was 31.52% (122/387). The median age at presentation was 49 years (interquartile range, 38-60), and 316 (81.65%) patients were male. In the multivariate logistic regression analysis, the factors associated with 30-day mortality included age (odds ratio [OR], 1.068; 95% confidence interval [CI], 1.040-1.096; P < 0.001), bilateral unreactive pupils (OR, 12.734; 95% CI, 4.129-39.270; P < 0.001), subdural hemorrhage (OR, 3.468; 95% CI, 1.305-9.218; P < 0.013), completely effaced basal cistern (OR, 3.52; 95% CI, 1.568-7.901; P = 0.002), intraoperative hypotension (OR, 11.532; 95% CI, 4.222-31.499; P < 0.001), preoperative activated partial thromboplastin time (OR, 6.905; 95% CI, 2.055-23.202; P = 0.002), and Injury Severity Score (OR, 1.081; 95% CI, 1.031-1.133; P = 0.002). CONCLUSIONS: In patients undergoing primary DC after traumatic brain injury, the predictors of 30-day mortality include age, bilateral unreactive pupils, subdural hemorrhage, completely effaced basal cistern, intraoperative hypotension, preoperative activated partial thromboplastin time, and Injury Severity Score.


Assuntos
Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/mortalidade , Craniectomia Descompressiva/tendências , Adulto , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Craniectomia Descompressiva/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
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