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1.
Medicine (Baltimore) ; 100(10): e24708, 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33725828

RESUMO

RATIONALE: Pathogeny of thrombosis in COVID-19 is related to interaction of SARS-Cov-2 with vascular wall through the angiotensin converting enzyme 2 (ACE2) receptor. This induces 2 pathways with immunothrombosis from activated endothelium (cytokine storm, leukocyte and platelet recruitment, and activation of coagulation extrinsic pathway), and rise of angiotensin II levels promoting inflammation. While thrombosis is widely described in COVID-19 patients admitted in intensive care unit, cerebrovascular diseases remains rare, in particular cerebral venous thrombosis (CVT). PATIENT CONCERNS: We describe 2 cases of women admitted during the spring of 2020 for intracranial hypertension signs, in stroke units in Great-east, a French area particularly affected by COVID-19 pandemia. DIAGNOSES: Cerebral imaging revealed extended CVT in both cases. The first case described was more serious due to right supratentorial venous infarction with hemorrhagic transformation leading to herniation. Both patients presented typical pneumonia due to SARS-Cov-2 infection, confirmed by reverse transcription polymerase chain reaction on a nasopharyngeal swab in only one. INTERVENTIONS: The first patient had to undergo decompressive craniectomy, and both patients were treated with anticoagulation therapy. OUTCOMES: Favorable outcome was observed for 1 patient. Persistent coma, due to bi thalamic infarction, remained for the other with more serious presentation. LESSONS: CVT, as a serious complication of COVID-19, has to be searched in all patients with intracranial hypertension syndrome. Data about anticoagulation therapy to prevent such serious thrombosis in SARS-Cov-2 infection are lacking, in particular in patients with mild and moderate COVID-19.


Assuntos
/complicações , Trombose Intracraniana/etiologia , Anticoagulantes/uso terapêutico , Craniectomia Descompressiva/métodos , Feminino , Humanos , Trombose Intracraniana/imunologia , Trombose Intracraniana/terapia , Pessoa de Meia-Idade , Adulto Jovem
2.
Lancet Neurol ; 20(2): 98-106, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33357512

RESUMO

BACKGROUND: Degenerative cervical myelopathy represents the most common form of non-traumatic spinal cord injury. This trial investigated whether riluzole enhances outcomes in patients undergoing decompression surgery for degenerative cervical myelopathy. METHODS: This multicentre, double-blind, placebo-controlled, randomised, phase 3 trial was done at 16 university-affiliated centres in Canada and the USA. Patients with moderate-to-severe degenerative cervical myelopathy aged 18-80 years, who had a modified Japanese Orthopaedic Association (mJOA) score of 8-14, were eligible. Patients were randomly assigned (1:1) to receive either oral riluzole (50 mg twice a day for 14 days before surgery and then for 28 days after surgery) or placebo. Randomisation was done using permuted blocks stratified by study site. Patients, physicians, and outcome assessors remained masked to treatment group allocation. The primary endpoint was change in mJOA score from baseline to 6 months in the intention-to-treat (ITT) population, defined as all individuals who underwent randomisation and surgical decompression. Adverse events were analysed in the modified intention-to-treat (mITT) population, defined as all patients who underwent randomisation, including those who did not ultimately undergo surgical decompression. This study is registered with ClinicalTrials.gov, NCT01257828. FINDINGS: From Jan 31, 2012, to May 16, 2017, 408 patients were screened. Of those screened, 300 were eligible (mITT population); 290 patients underwent decompression surgery (ITT population) and received either riluzole (n=141) or placebo (n=149). There was no difference between the riluzole and placebo groups in the primary endpoint of change in mJOA score at 6-month follow-up: 2·45 points (95% CI 2·08 to 2·82 points) versus 2·83 points (2·47 to 3·19), difference -0·38 points (-0·90 to 0·13; p=0·14). The most common adverse events were neck or arm or shoulder pain, arm paraesthesia, dysphagia, and worsening of myelopathy. There were 43 serious adverse events in 33 (22%) of 147 patients in the riluzole group and 34 serious adverse events in 29 (19%) of 153 patients in the placebo group. The most frequent severe adverse events were osteoarthrosis of non-spinal joints, worsening of myelopathy, and wound complications. INTERPRETATION: In this trial, adjuvant treatment for 6 weeks perioperatively with riluzole did not improve functional recovery beyond decompressive surgery in patients with moderate-to-severe degenerative cervical myelopathy. Whether riluzole has other benefits in this patient population merits further study. FUNDING: AOSpine North America.


Assuntos
Vértebras Cervicais/cirurgia , Craniectomia Descompressiva/métodos , Degeneração do Disco Intervertebral/tratamento farmacológico , Degeneração do Disco Intervertebral/cirurgia , Fármacos Neuroprotetores/uso terapêutico , Procedimentos Neurocirúrgicos/métodos , Riluzol/uso terapêutico , Compressão da Medula Espinal/tratamento farmacológico , Compressão da Medula Espinal/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Método Duplo-Cego , Determinação de Ponto Final , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fármacos Neuroprotetores/efeitos adversos , Dor Pós-Operatória/epidemiologia , Riluzol/efeitos adversos , Resultado do Tratamento
3.
Sci Rep ; 10(1): 22242, 2020 12 17.
Artigo em Inglês | MEDLINE | ID: mdl-33335178

RESUMO

Decompressive craniectomy (DC) is often required to manage rising intracranial pressure after traumatic brain injury (TBI). Syndrome of the trephine (SoT) is a reversible neurologic condition that often occurs following DC as a result of the unrepaired skull. The purpose of the present study is to characterize neurological impairment following TBI in rats with an unrepaired craniectomy versus rats with a closed cranium. Long Evans male rats received a controlled cortical impact (CCI) over the caudal forelimb area (CFA) of the motor cortex. Immediately after CCI, rats received either a hemi-craniectomy (TBI Open Skull Group) or an immediate acrylic cranioplasty restoring cranial anatomy (TBI Closed Skull Group). Motor performance was assessed on a skilled reaching task on post-CCI weeks 1-4, 8, 12, and 16. Three weeks after the CCI injury, the TBI Closed Skull Group demonstrated improved motor performance compared to TBI Open Skull Group. The TBI Closed Skull Group continued to perform better than the TBI Open Skull Group throughout weeks 4, 8, 12 and 16. The protracted recovery of CFA motor performance demonstrated in rats with unrepaired skulls following TBI suggests this model may be beneficial for testing new therapeutic approaches to prevent SoT.


Assuntos
Lesões Encefálicas Traumáticas/fisiopatologia , Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/efeitos adversos , Atividade Motora , Animais , Comportamento Animal , Lesões Encefálicas Traumáticas/diagnóstico , Craniectomia Descompressiva/métodos , Modelos Animais de Doenças , Pressão Intracraniana , Imagem por Ressonância Magnética , Córtex Motor/fisiopatologia , Desempenho Psicomotor , Ratos
4.
PLoS One ; 15(10): e0232561, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33031373

RESUMO

BACKGROUND: Decompressive craniectomy is an important surgical treatment for patients with severe traumatic brain injury (TBI). Several reports have been published on the efficacy of non-watertight sutures in duraplasty performed in decompressive craniectomy. This study sought to determine the safety and feasibility of the non-suture dural closure technique in decompressive craniectomy. METHODS: A total of 106 patients were enrolled at a single trauma center between January 2017 and December 2018. We retrospectively collected data and classified the patients into non-suture and suture duraplasty craniectomy groups. We compared the characteristics of patients and their intra/postoperative findings such as operative time, blood loss, imaging findings, complications, and Glasgow Outcome Scale scores. RESULTS: There were 37 and 69 patients in the non-suture and suture duraplasty groups, respectively. There were no significant differences between the two groups concerning general characteristics. The operative time was significantly lower in the non-suture duraplasty group than in the suture duraplasty group (150 min vs. 205 min; p = 0.002). Furthermore, blood loss was significantly less severe in the non-suture duraplasty group than in the suture duraplasty group (1000 mL vs. 1500 mL; p = 0.028). There were no other significant differences. CONCLUSION: Non-suture duraplasty involved shorter operative times and less severe blood losses than suture duraplasty. Other complications and prognoses were similar across groups. Therefore, the non-suture duraplasty in decompressive craniectomy is a safe and feasible surgical technique.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/métodos , Dura-Máter/cirurgia , Adulto , Perda Sanguínea Cirúrgica , Feminino , Escala de Resultado de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos sem Sutura , Resultado do Tratamento
5.
Medicine (Baltimore) ; 99(30): e21251, 2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-32791701

RESUMO

INTRODUCTION: Cranioplasty following decompressive craniectomy is routinely performed to restore integrity of skull and improve neurological function. However, reconstructing the cranial defect brings many challenges to neurosurgeons and search for ideal implant materials is one of the most controversial issues. Although many studies have compared the outcomes of titanium and polyetheretherketone (PEEK) cranioplasty, yet no prospective study exists to guide the choice of titanium and PEEK materials. METHODS/DESIGN: A non-randomized, partially blinded, prospective cohort study is described that comprehensively compares the long-term outcomes of titanium cranioplasty versus PEEK cranioplasty. One hundred forty-five patients for each group will be recruited. Eligible patients are those with cranial defect due to traumatic brain injury (≥ 16 years), defect size is over 25 cm and they must agree to participate in the trial. Each participant is evaluated before surgery, on discharge, 3, 6, and 12 months after cranioplasty. The primary outcome is the infection, implant failure and implant deformation requiring revision surgery within 12 months. Secondary outcomes include postoperative complication rate, neurological outcomes, motor function, and cosmetic outcome over a 6-month period. DISCUSSION: Search for ideal implant materials is throughout the history of cranioplasty. This study will provide robust evidence for the choice of cranioplasty materials. TRIAL REGISTRATION NUMBER: ChiCTR2000033406.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/métodos , Titânio/uso terapêutico , Humanos , Cetonas/uso terapêutico , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados não Aleatórios como Assunto , Polietilenoglicóis/uso terapêutico , Estudos Prospectivos
6.
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
7.
Stroke ; 51(8): 2404-2410, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32646327

RESUMO

BACKGROUND AND PURPOSE: Infarct volumes predict malignant infarcts in patients undergoing decompressive hemicraniectomy (DH) for large middle cerebral artery territory infarcts. The aim of the study was to determine the optimal magnetic resonance imaging infarct volume threshold that predicts a catastrophic outcome at 1 year (modified Rankin Scale score of 5 or death). METHODS: We included consecutive patients who underwent DH for large middle cerebral artery infarcts. We analyzed infarct volumes before DH with semi-automated methods on b1000 diffusion-weighted imaging sequences and apparent diffusion coefficient maps. We studied infarct volume thresholds for prediction of catastrophic outcomes, and analyzed sensitivity, specificity, and the area under the curve, a value ≥0.70 indicating an acceptable prediction. RESULTS: Of 173 patients (109 men, 63%; median age 53 years), 42 (24.3%) had catastrophic outcomes. Magnetic resonance imaging b1000 diffusion-weighted imaging and apparent diffusion coefficient infarct volumes were associated to the occurrence of 1-year catastrophic outcome (adjusted odds ratio, 9.17 [95% CI, 2.00-42.04] and odds ratio, 4.18 [95% CI, 1.33-13.19], respectively, per 1 log increase). The optimal volume cutoff of were 211 mL on b1000 diffusion-weighted imaging and 181 mL on apparent diffusion coefficient maps. The 2 methods showed similar sensitivities and specificities and overlapping area under the curve of 0.64 (95% CI, 0.54-0.74). CONCLUSIONS: In patients with large middle cerebral artery infarcts, optimal magnetic resonance imaging infarct volume thresholds showed poor accuracy and low specificity to predict 1-year catastrophic outcome, with different b1000 diffusion-weighted imaging and apparent diffusion coefficient thresholds. In the setting of DH, optimal infarct volumes alone should not be used to deny DH, irrespectively of the method used.


Assuntos
Doença Catastrófica/terapia , Craniectomia Descompressiva/tendências , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/cirurgia , Adulto , Craniectomia Descompressiva/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Resultado do Tratamento
8.
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
9.
World Neurosurg ; 139: 215-218, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32304887

RESUMO

BACKGROUND: The American Stroke Association and the European Stroke Organization have established guidelines on cerebral venous thrombosis (CVT); however, questions remain when an individual case does not fall within the inclusion criteria on which these guidelines are based. This is relevant when considering the use of anticoagulation in cases of CVT regarding whether or not associated hemorrhage is present and whether the hemorrhage is currently expanding. CASE DESCRIPTION: A 16-year-old right-handed female G2P2 (gravidity 2 [2 pregnancies] and parity 2 [2 live births after at least 24 weeks) presented 8 days postpartum with complaints of slurred speech, right facial droop, and right upper extremity numbness that had progressed over the course of 4 hours before presentation. On imaging the patient had a CVT with associated hemorrhage progressing in size at serial 6-hour stability computed tomography scans for 24 hours post arrival. At 24 hours the patient went into disseminated intravascular coagulation and demonstrated signs of herniation. The patient underwent an emergency hemicraniectomy along with a right frontal external ventricular drain for intracranial pressure monitoring. Most recently, the patient had a Glasgow Coma Scale score of 15 and had a modified Rankin Scale score of 4 and was ultimately discovered to have antiphospholipid syndrome. CONCLUSIONS: This case of CVT demonstrates the need for critically reading guidelines, as in this case the time to anticoagulation treatment was shorter than in cases included in guideline construction and repeated computed tomography examination demonstrated expansion suggesting it is unsuitable for immediate anticoagulation. Certain cases may fall outside of the study parameters on which guidelines are constructed, and clinicians should be aware of these exceptions.


Assuntos
Anticoagulantes/uso terapêutico , Síndrome Antifosfolipídica/diagnóstico , Veias Cerebrais/diagnóstico por imagem , Craniectomia Descompressiva/métodos , Coagulação Intravascular Disseminada/diagnóstico , Hemorragias Intracranianas/diagnóstico por imagem , Trombose Intracraniana/diagnóstico por imagem , Trombose Intracraniana/terapia , Transtornos Puerperais/diagnóstico por imagem , Transtornos Puerperais/terapia , Adolescente , Síndrome Antifosfolipídica/complicações , Angiografia por Tomografia Computadorizada , Progressão da Doença , Coagulação Intravascular Disseminada/etiologia , Coagulação Intravascular Disseminada/terapia , Feminino , Humanos , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/terapia , Trombose Intracraniana/etiologia , Guias de Prática Clínica como Assunto , Transtornos Puerperais/etiologia , Tomografia Computadorizada por Raios X , Ventriculostomia
10.
World Neurosurg ; 139: e293-e296, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32298833

RESUMO

BACKGROUND: Decompressive hemicraniectomy (DHC) is well established as an effective life-saving intervention. Although literature documents a correlation between mortality and hemicraniectomy flap size, no literature exists demonstrating whether a larger flap may be achieved with 3-pin fixation devices versus nonfixed positioning (e.g., occipital headrest, gel donut). Therefore, positioning for DHC remains the preference of the institution and attending physician. METHODS: Patients undergoing DHC during 2005-2016 were identified using Current Procedural Terminology codes. Inclusion criteria were: operative note available in the electronic medical record and postoperative head computed tomography (hCT). Exclusion criteria were: age <18 years, missing data in electronic medical record, no postoperative hCT performed, and craniectomy not done with intention of performing a hemicraniectomy (i.e., craniotomy converted to craniectomy). Anteroposterior diameter of the hemicraniectomy flap was measured in millimeters on the postoperative hCT. The average diameter was compared between the fixed positioning and nonfixed positioning groups. RESULTS: Analysis included 522 patients who met inclusion criteria; 363 were in the fixed positioning group, and 159 were in the nonfixed positioning group. The average hemicraniectomy diameter was 132.17 mm in the fixed positioning group, and 129.74 mm in the nonfixed positioning group, which was statistically significant (P = 0.027). CONCLUSIONS: This is the first large-scale single-institution study evaluating whether operative positioning for DHC affects the size of a hemicraniectomy flap. Positioning in 3-point fixation led to a statistically significant larger average diameter compared with nonfixed positioning. This indicates that the risks associated with pin fixation as well as additional time spent in positioning in this fashion are offset by the ability to obtain a larger hemicraniectomy flap, which is associated with decreased mortality.


Assuntos
Craniectomia Descompressiva/métodos , Posicionamento do Paciente/métodos , Retalhos Cirúrgicos , Adulto , Craniectomia Descompressiva/mortalidade , Feminino , Humanos , Masculino , Estudos Retrospectivos , Resultado do Tratamento
11.
J Neurol Neurosurg Psychiatry ; 91(5): 469-474, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32165377

RESUMO

BACKGROUND: Decompressive hemicraniectomy (DH) increases survival without severe dependency in patients with large middle cerebral artery (LMCA) infarcts. The objective was to identify predictors of 1-year outcome after DH for LMCA infarct. METHODS: We conducted this study in consecutive patients who underwent DH for LMCA infarcts, in a tertiary stroke centre. Using multivariable logistic regression analyses, we evaluated predictors of (1) 30-day mortality and (2) poor outcome after 1 year (defined as a modified Rankin Scale score of 4-6) in 30-day survivors. RESULTS: Of 212 patients (133 men, 63%; median age 51 years), 35 (16.5%) died within 30 days. Independent predictors of mortality were infarct volume before DH (OR 1.10 per 10 mL increase, 95% CI 1.04 to 1.16), delay between symptom onset and DH (OR 0.41, 95% CI 0.23 to 0.73 per 12 hours increase) and midline shift after DH (OR 2.59, 95% CI 1.09 to 6.14). The optimal infarct volume cut-off to predict death was 210 mL or more. Among the 177 survivors, 77 (43.5%) had a poor outcome at 1 year. Independent predictors of poor outcome were age (OR 1.08 per 1 year increase, 95% CI 1.03 to 1.12) and weekly alcohol consumption of 300 g or more (OR 5.30, 95% CI 2.20 to 12.76), but not infarct volume. CONCLUSION: In patients with LMCA infarcts treated by DH, stroke characteristics (infarct volume before DH, midline shift after DH and early DH) predict 30-day mortality, while patients' characteristics (age and excessive alcohol intake) predict 1-year outcome survivors.


Assuntos
Craniectomia Descompressiva , Infarto da Artéria Cerebral Média/cirurgia , Adolescente , Adulto , Fatores Etários , Idoso , Alcoolismo/complicações , Craniectomia Descompressiva/métodos , Craniectomia Descompressiva/mortalidade , Craniectomia Descompressiva/estatística & dados numéricos , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/mortalidade , Infarto da Artéria Cerebral Média/patologia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neuroimagem , Curva ROC , Fatores de Risco , Sobreviventes/estatística & dados numéricos , Resultado do Tratamento , Adulto Jovem
12.
World Neurosurg ; 138: 9-18, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32084616

RESUMO

BACKGROUND: Severe traumatic brain injuries (TBIs) are a principal cause of neurologic dysfunction and death in the pediatric population. After medical management, the second-tier treatment is decompressive craniectomy in cases of intractable intracranial pressure (ICP) elevation. This literature review offers evidence of early (within 24 hours) and ultraearly (6-12 hours) decompressive craniectomy as an effective form of management for severe TBI in the pediatric population. METHODS: We conducted a literature review of articles published from 1996 to 2019 to elucidate neurologic outcomes after early decompressive craniectomy in pediatric patients who suffered a severe TBI. Time to decompressive craniectomy and neurologic outcomes were recorded and reported descriptively. Qualitative data describe clinically important correlations between pre- and postoperative ICP levels and improved postoperative neurologic outcomes. RESULTS: Seventy-eight patients were included in this study. The median age of patients at diagnosis was 10 years of age (range, 1 months to 19 years). Median admission Glasgow Coma Scale score was 5 (range, 3-8). Time to decompressive craniectomy ranged from 1 to 24 hours. Median peak preoperative ICP was 40 (range, 3-90; n = 49). Median postoperative ICP was 20 (range, 0-80; n = 33). Median Glasgow Outcome Scale (GOS) score at discharge was 2 (range, 1-5; n = 11). Median GOS score at 3- and 6-month follow-up was 3 (range, 1-5; n = 11). Median GOS score at 7- to 23-month follow-up was 4 (range, 1-5; n = 29). Median GOS score at 24- to 83-month follow-up was 4 (range, 1-5; n = 31). Median modified Rankin Scale score at discharge was 3 (range, 2-4; n = 6). Median modified Rankin Scale score at 6- to 48-month follow-up was 2 (range, 0-3; n = 6). Median Rancho Los Amigos Scale (RLAS) score at discharge was 6 (range, 4-8; n = 5). Median RLAS score at 6-month follow-up was 10 (range, 8-10; n = 5). CONCLUSIONS: Early (within 24 hours), with consideration of ultraearly (within 6-12 hours), decompressive craniectomy for severe TBI should be offered to pediatric patients in settings with refractory ICP elevation. Reduction of ICP allows for prompt disruption of pathophysiologic cascades and improved neurologic outcomes.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Tempo para o Tratamento , Resultado do Tratamento , Adulto Jovem
13.
Medicina (Kaunas) ; 56(2)2020 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-32093047

RESUMO

BACKGROUND AND OBJECTIVES: Bedside sonographic duplex technique (SDT) may be used as an adjunct to cranial computed tomography (CCT) to monitor brain-injured patients after decompressive craniectomy (DC). The present study aimed to assess the value of SDT in repeated measurements of ventricle dimensions in patients after DC by comparing both techniques. MATERIALS AND METHODS: Retrospective assessment of 20 consecutive patients after DC for refractory intracranial pressure (ICP) increase following subarachnoid hemorrhage (SAH), bleeding and trauma which were examined by SDT and CCT in the context of routine clinical practice. Whenever a repeated CCT was clinically indicated SDT examinations were performed within 24 hours and correlated via measurement of the dimensions of all four cerebral ventricles. Basal cerebral arteries including pathologies such as vasospasms were also evaluated in comparison to selected digital subtraction angiography (DSA). RESULTS: Repeated measurements of all four ventricle diameters showed high correlation between CCT and SDT (right lateral r = 0.997, p < 0.001; left lateral r = 0.997, p < 0.001; third r = 0.991, p < 0.001, fourth ventricle r = 0.977, p < 0.001). SDT performed well in visualizing basal cerebral arteries including pathologies (e.g., vasospasms) as compared to DSA. CONCLUSIONS: Repeated SDT measurements of the dimensions of all four ventricles in patients after DC for refractory ICP increase delivered reproducible results comparable to CCT. SDT may be considered as a valuable bedside monitoring tool in patients after DC.


Assuntos
Craniectomia Descompressiva/métodos , Hipertensão Intracraniana/etiologia , Monitorização Fisiológica/normas , Sistemas Automatizados de Assistência Junto ao Leito/tendências , Ultrassonografia Doppler Dupla/métodos , Adulto , Idoso , Feminino , Humanos , Hipertensão Intracraniana/diagnóstico , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Monitorização Fisiológica/estatística & dados numéricos , Estudos Retrospectivos
14.
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
15.
J Clin Neurosci ; 74: 98-103, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32033859

RESUMO

BACKGROUND: Secondary cranioplasty (CP) plays a key role in restoring cranial vault anatomy and normal brain function following decompressive craniectomy (DC). The scientific literature provides only fragmentary information regarding the best timing and material for CP, making a direct comparison of different materials difficult. OBJECT: To identify and report according to STROBE guidelines local trends in choice of materials for CP, complications rate and surgical outcomes. METHODS: We conducted an audit on secondary CP covering the last 20 years of surgical practice at our Institution. Custom-made CP used over the years were made of: porous hydroxyapatite (PHA), polymetylmethacrylate (PMMA), polyetheretherketone (PEEK), acrylic and titanium. The primary endpoint of this study was the incidence of postoperative complications, such as: implant infection, fracture and dislocation. Secondary endpoints were the followings: patients satisfaction with cosmetic result, rate of implant integration, and long-term neurological outcome. RESULTS: A total of 218 patients were included, given the predominance of PHA (Group A) or PMMA (Group B) CP, a direct comparison was made only between those two groups. Overall reoperation rate was 6.5% versus 28%; implants' osseointegration rate was of 69% versus 24%; satisfaction rate was 66% versus 44%, in Group A and B respectively. CONCLUSIONS: This single-centre study provides Level 3 evidence that PHA yields better outcomes than PMMA CP. Designing a management algorithm for planning and executing CP is difficult for clinical and organizational reasons; till a widespread consensus is reached, neurosurgeons with subspecialty interest in neurotrauma should favor pragmatism and patient safety over costs.


Assuntos
Durapatita/normas , Cetonas/normas , Polietilenoglicóis/normas , Próteses e Implantes , Procedimentos Cirúrgicos Reconstrutivos/métodos , Adulto , Craniectomia Descompressiva/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osseointegração , Satisfação do Paciente , Complicações Pós-Operatórias/etiologia , Reoperação , Estudos Retrospectivos , Crânio/cirurgia , Titânio
16.
World Neurosurg ; 137: e430-e436, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32035212

RESUMO

BACKGROUND: Decompressive craniectomy (DC) is a widely used treatment for refractory high intracranial pressure (ICP). While the Brain Trauma Foundation guidelines favor large DC, there remains a lack of consensus regarding the optimal size of DC in relationship to the patient's head size. The aim of this study is to determine the optimal size of DC to effectively control refractory ICP in traumatic brain injury and to measure that size with a method that takes into consideration the patient's head size. METHODS: All cases of unilateral DC performed to control refractory increased ICP due to cerebral edema during a 7½-year period were included. Demographic and injury-related data were collected by retrospective chart review. The patients were categorized in 2 groups: 21 patients with a "small flaps" and 9 patients with a "large flap." RESULTS: Two groups had similar preoperative characteristics. The amount of cerebrospinal fluid drained and the doses of hyperosmolar therapy given were not different between the 2 groups. The postoperative ICP was significantly lower for the large craniectomy flap group: 13.3 mm Hg confidence interval 99% [12.7, 13.8] versus 16.9 mm Hg confidence interval 99% [16.5, 17.2] (P = 0.01), and this difference was maintained for 96 hours postoperatively. CONCLUSIONS: Better ICP control was achieved in patients who underwent a large decompressive craniectomy (ratio >65%) when compared with smaller craniectomy sizes. The proposed method of measuring the craniectomy size, to our knowledge, is the first to take into account the patient's head size and can be easily measured intraoperatively.


Assuntos
Edema Encefálico/cirurgia , Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/métodos , Cabeça/anatomia & histologia , Hipertensão Intracraniana/cirurgia , Retalhos Cirúrgicos , Adolescente , Adulto , Edema Encefálico/etiologia , Lesões Encefálicas Traumáticas/complicações , Feminino , Humanos , Hipertensão Intracraniana/etiologia , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
17.
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
18.
World Neurosurg ; 137: 408-414, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32105874

RESUMO

OBJECTIVE: Cerebral venous thrombosis (CVT) is a rare type of stroke whose pathophysiology differs from arterial stroke. CVT is treated with systemic anticoagulant therapy even in the setting of intracerebral hemorrhage. Patients who do not respond adequately may require decompressive surgery. The study objective was to examine the timing of anticoagulation in patients with CVT who require decompressive surgery through systematic literature review and consecutive case series. METHODS: A review of the literature was performed through PubMed using key word search to identify case series and cohort studies examining timing of anticoagulation following decompressive surgery. Our case series included 4 patients who had decompressive surgery for hemorrhagic CVT between 1 January, 2015 and 31 December, 2016 at our comprehensive stroke center. RESULTS: The literature review summarizes 243 patients from 15 studies whose timing of anticoagulation varied. The review suggests anticoagulation can be safely resumed at 48 hours postoperatively based on larger series and as early as 12 hours in smaller series, especially when delivered as a half or prophylactic dose. In our case series, timing of anticoagulation varied slightly but was started or resumed within 38-44 hours postoperatively in 3 patients and was started at the time of decompressive surgery without interruption in 1 patient. No patient had worsening hemorrhage or new hemorrhage while 2 patients rethrombosed. CONCLUSIONS: Despite the lack of high-quality studies, this systematic review of patients with CVT requiring decompressive surgery indicates that anticoagulation can be safely initiated or resumed around 24-48 hours postoperatively; our series supports the existing literature.


Assuntos
Anticoagulantes/administração & dosagem , Craniectomia Descompressiva/métodos , Heparina/administração & dosagem , Trombose dos Seios Intracranianos/terapia , Adulto , Anticoagulantes/efeitos adversos , Angiografia Cerebral , Hemorragia Cerebral/induzido quimicamente , Procedimentos Endovasculares , Feminino , Heparina/efeitos adversos , Antagonistas de Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/induzido quimicamente , Período Pós-Operatório , Protaminas/uso terapêutico , Trombectomia , Terapia Trombolítica , Fatores de Tempo
19.
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
20.
World Neurosurg ; 137: 18-23, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31954912

RESUMO

BACKGROUND: Cavernous sinus dural arteriovenous fistulas (CS dAVFs) occasionally behave aggressively (e.g., intracranial hemorrhage, venous infarction, seizures) depending on the drainage flow and presence of a collateral route of cortical or basal cerebral venous drainage. When a CS dAVF with aggressive behavior is encountered, a radical cure is required to avoid catastrophic deficits. However, conventional transvenous cavernous sinus (CS) embolization via the inferior petrosal sinus does not always achieve shunt obliteration. We herein report a case of surgical venous drainage disconnection in an 83-year-old woman with a CS dAVF. CASE DESCRIPTION: The patient presented with coma and anisocoria due to intracranial hemorrhage. Because of the patient's critical condition, we had no choice but to perform emergency decompressive craniectomy and hematoma evacuation without detailed preoperative hemodynamic information obtained by digital subtraction angiography. Postoperative digital subtraction angiography showed a CS dAVF with retrograde venous drainage of the deep middle cerebral vein (DMCV) and varix formation in the affected DMCV, causing hemorrhagic episodes. Five days after admission, the patient's neurologic state worsened because of rebleeding from the varix, which had increased in size. The percutaneous transvenous approach failed because of compartmentalization within the CS. Open surgery was performed; the deep vasculature was exposed by the transsylvian approach, and the arterialized DMCV was permanently clipped at its proximal segment with disconnection from the venous varix and fistulous point. Shunt obliteration was successfully achieved. CONCLUSIONS: Surgical venous drainage disconnection from the fistulous point may be an alternative radical therapy for CS dAVFs with aggressive behaviors.


Assuntos
Malformações Vasculares do Sistema Nervoso Central/terapia , Embolização Terapêutica/métodos , Varizes/terapia , Idoso de 80 Anos ou mais , Anisocoria/etiologia , Encefalopatias/cirurgia , Seio Cavernoso , Coma/etiologia , Craniectomia Descompressiva/métodos , Feminino , Giro do Cíngulo , Hérnia/complicações , Herniorrafia/métodos , Humanos , Hemorragias Intracranianas/terapia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Ruptura Espontânea/etiologia , Ruptura Espontânea/terapia
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