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1.
World Neurosurg ; 133: e135-e148, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31491576

RESUMO

BACKGROUND: Decompressive hemicraniectomy (DHC) is widely applied for patients with traumatic brain injury (TBI). Although previous studies have indicated that DHC can lead to similar or worse outcomes compared with medical treatment (MT) in patients with TBI, recent trials have suggested the benefit of DHC for neurologic function recovery. Therefore, we performed this meta-analysis to assess the efficacy and functional outcomes of DHC in patients with TBI. METHODS: In accordance with PRISMA guidelines, we searched English and Chinese databases to identify relevant randomized controlled trials (RCTs) reporting DHC for TBI. The outcomes measures included mortality, favorable outcome, unfavorable outcome, postoperative intracranial pressure (ICP), adverse events with hematoma, and hospital stay. RESULTS: Seven RCTs with a total of 779 patients with TBI were included in this meta-analysis. Compared with the MT group, the DHC group demonstrated significantly lower rates of mortality (P < 0.00001), postoperative ICP (P < 0.00001), and postoperative hematoma (P = 0.01), and significantly shorter hospital length of stay (P = 0.02). However, the rate of unfavorable outcomes was higher in the DHC group compared with the MT group (P = 0.0001). CONCLUSIONS: Our results indicate that DHC could be effective in reducing the mortality rate, incidence of ICP, and hospital length of stay in patients with TBI. However, the proportion of patients surviving with unfavorable outcomes was significantly higher in the DHC group compared with the MT group. Despite the limitations of the meta-analysis, our findings target extremely important topic and provide important evidence to facilitate clinical decision making.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Adulto , Dano Encefálico Crônico/etiologia , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/mortalidade , Criança , Humanos , Hipertensão Intracraniana/etiologia , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento
2.
World Neurosurg ; 131: 385-390, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31658580

RESUMO

Traumatic brain injury (TBI) represents a major public health concern worldwide, with no significant change in its epidemiology over the last 30 years. After TBI, the primary injury induces irreversible brain damage, which is untreatable. The subsequent secondary injury plays a critical role in the clinical prognosis because without effective treatment it will provide additional tissue damage. The resulting scenario is the rise in intracranial pressure (ICP) with the development of progressive neurological deficits. Current optimal management is based on a progressive, target-driven approach combining both medical and surgical treatment strategies among which is decompressive hemicraniectomy. With the advent of technology, research in the glymphatic pathways, and advances in microscopic surgery, a novel surgical technique-the cisternostomy-has emerged that holds promise in managing rising ICP in TBI-affected patients. In this article we describe the rationale for cisternostomy, an emerging microneurosurgical approach for the management of moderate to severe TBI.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Procedimentos Neurocirúrgicos/métodos , Estomia/métodos , Contraindicações de Procedimentos , Craniectomia Descompressiva/métodos , Drenagem/métodos , Humanos , Hipertensão Intracraniana/etiologia , Hipertensão Intracraniana/cirurgia , Ilustração Médica , Microcirurgia/métodos
3.
No Shinkei Geka ; 47(9): 949-956, 2019 Sep.
Artigo em Japonês | MEDLINE | ID: mdl-31564655

RESUMO

The cognitive function of children who underwent surgical therapy after a traumatic brain injury is poorly studied. In this study, we investigated the characteristics of 27 children who received surgical therapy at our institution. The children were between 1 and 16 years of age, of which 15 had cognitive dysfunction. Their Glasgow Coma Scale score at the acute stage of dysfunction was worse than in children who did not have cognitive dysfunction. Acute subdural hematoma was more frequent in the cognitive dysfunction group. Moreover, all children in this group showed brain injury by imaging analysis. Differences in imaging characteristics and the association with cognitive dysfunction could not be readily associated with a specific injury. Memory and verbal disorder were the most common cognitive dysfunctions:these symptoms were present among children of all ages;conversely, behavior disorder, impaired attention, and infeasibility were limited to the children under 9 years of age. Since the immature brain is developing, the acquisition of new abilities may be blocked by the injury;thus, we speculate that brain injury at a younger age causes greater cognitive dysfunction.


Assuntos
Lesões Encefálicas Traumáticas , Lesões Encefálicas , Disfunção Cognitiva , Adolescente , Lesões Encefálicas Traumáticas/cirurgia , Criança , Pré-Escolar , Disfunção Cognitiva/etiologia , Escala de Coma de Glasgow , Humanos , Lactente
4.
World Neurosurg ; 132: e21-e27, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31521754

RESUMO

BACKGROUND: To investigate role of Low-dose, Early Fresh frozen plasma Transfusion (LEFT) therapy in preventing perioperative coagulopathy and improving long-term outcome after severe traumatic brain injury (TBI). METHODS: A prospective, single-center, parallel-group, randomized trial was designed. Patients with severe TBI were eligible. We used a computer-generated randomization list and closed opaque envelops to randomly allocate patients to treatment with fresh frozen plasma (5 mL/kg body weight; LEFT group) or normal saline (5 mL/kg body weight; NO LEFT group) after admission in the operating room. RESULTS: Between January 1, 2018, and November 31, 2018, 63 patients were included and randomly allocated to LEFT (n = 28) and NO LEFT (n = 35) groups. The final interim analysis included 20 patients in the LEFT group and 32 patients in the NO LEFT group. The study was terminated early for futility and safety reasons because a high proportion of patients (7 of 20; 35.0%) in the LEFT group developed new delayed traumatic intracranial hematoma after surgery compared with the NO LEFT group (3 of 32; 9.4%) (relative risk, 5.205; 95% confidence interval, 1.159-23.384; P = 0.023). Demographic characteristics and indexes of severity of brain injury were similar at baseline. CONCLUSIONS: LEFT therapy was associated with a higher incidence of delayed traumatic intracranial hematoma than normal fresh frozen plasma transfusion in patients with severe TBI. A restricted fresh frozen plasma transfusion protocol, in the right clinical setting, may be more appropriate in patients with TBIs.


Assuntos
Transfusão de Sangue/métodos , Lesões Encefálicas Traumáticas/terapia , Plasma , Idoso , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/cirurgia , Craniotomia , Método Duplo-Cego , Feminino , Hematoma Subdural Agudo/cirurgia , Hematoma Subdural Agudo/terapia , Humanos , Hemorragia Intracraniana Traumática/complicações , Hemorragias Intracranianas/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Prevenção Secundária , Resultado do Tratamento
5.
J Clin Neurosci ; 69: 61-66, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31451377

RESUMO

Age is an important prognostic factor for patients with traumatic brain injury (TBI), and worse treatment outcomes have been reported in elderly patients. Therefore, proper treatment is needed for the increasing number of elderly patients with TBI. We aimed to analyze predictive factors of favorable treatment outcomes (FTO) in elderly patients. Clinical and radiological data from 493 patients with TBI who visited a single institute were retrospectively collected from January 2014 to December 2015. We compared the characteristics of the elderly group (individuals above 65 years) and younger group (16-65 years). We analyzed the characteristics and outcomes in both groups and the factors related to the Glasgow outcome scale-extended score at 6 months after injury in 170 elderly patients. The treatment outcomes were dichotomized into favorable and unfavorable groups. In the elderly group, the proportion of female patients and the incidence of subdural hemorrhage (SDH) were higher than in the younger group. Among the 170 elderly patients, 62 had pure SDH, and 21 of the 62 with pure SDH had undergone surgical treatment. Compared with other types of intracranial hemorrhage, FTO was as high as 85.5%, and mortality was as low as 11.3% in patients with pure SDH. High initial Glasgow coma scale score, low injury severity score, and normal pupillary reflex were significantly related to FTO in multivariate analysis. Therefore, active therapeutic strategies, including surgery should be considered for elderly patients with pure SDH without intra-parenchymal injury.


Assuntos
Lesões Encefálicas Traumáticas/patologia , Resultado do Tratamento , Adulto , Idoso , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/cirurgia , Feminino , Escala de Resultado de Glasgow , Hematoma Subdural/epidemiologia , Hematoma Subdural/etiologia , Hematoma Subdural/cirurgia , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Estudos Retrospectivos
6.
Medicine (Baltimore) ; 98(35): e17012, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31464960

RESUMO

BACKGROUND: Percutaneous tracheostomy, almost associated with cough reflex and hemodynamic fluctuations, is a common procedure for traumatic brain injury (TBI) patients, especially those in neurosurgery intensive care units (NICUs). However, there are currently a lack of effective preventive measures to reduce the risk of secondary brain injury. The aim of this study was to compare the effect of dexmedetomidine (DEX) vs sufentanil during percutaneous tracheostomy in TBI patients. METHODS: The 196 TBI patients who underwent percutaneous tracheostomy were randomized divided into 3 groups: group D1 (n = 62, DEX infusion at 0.5 µg·kg for 10 minutes, then adjusted to 0.2-0.7 µg·kg·hour), group D2 (n = 68, DEX infusion at 1 µg·kg for 10 minutes, then adjusted to 0.2-0.7 µg·kg·hour), and group S (n = 66, sufentanil infusion 0.3 µg·kg for 10 minutes, then adjusted to 0.2-0.4 µg·kg·hour). The bispectral index (BIS) of all patients was maintained at 50 to 70 during surgery. Anesthesia onset time, hemodynamic variables, total cumulative dose of DEX/sufentanil, total doses of rescue propofol and fentanyl, time to first dose of rescue propofol and fentanyl, number of intraoperative patient movements and cough reflexes, adverse events, and surgeon satisfaction score were recorded. RESULTS: Anesthesia onset time was significantly lower in group D2 than in both other groups (14.35 ±â€Š3.23 vs 12.42 ±â€Š2.12 vs 13.88 ±â€Š3.51 minutes in groups D1, D2, and S, respectively; P < .001). Both heart rate and mean arterial pressure during percutaneous tracheostomy were more stable in group D2. Total doses of rescue propofol and fentanyl were significantly lower in group D2 than in group D1 (P < .001). The time to first dose of rescue propofol and fentanyl were significantly longer in group D2 than in both other groups (P < .001). The number of patient movements and cough reflexes during percutaneous tracheostomy were lower in group D2 than in both other groups (P < .001). The overall incidences of tachycardia and hypertension (which required higher doses of esmolol and urapidil, respectively) were also lower in group D2 than in both other groups (P < .05). Three patients in group S had respiratory depression compared to X in the D1 group and X in the D2 group. The surgeon satisfaction score was significantly higher in group D2 than in both other groups (P < .05). CONCLUSIONS: During percutaneous tracheostomy, compared with sufentanil, DEX (1 µg·kg for 10 minutes, then adjusted to 0.2-0.7 µg·kg·hour) can provide the desired attenuation of the hemodynamic response without increased adverse events. Consequently, DEX could be used safely and effectively during percutaneous tracheostomy in TBI patients.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Sufentanil/administração & dosagem , Traqueostomia/métodos , Adulto , Tosse/prevenção & controle , Dexmedetomidina/efeitos adversos , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Hipnóticos e Sedativos/efeitos adversos , Laringismo/prevenção & controle , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sufentanil/efeitos adversos
7.
J Craniofac Surg ; 30(7): 2217-2223, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31469742

RESUMO

This study aimed to investigate the clinical efficacy of intracranial pressure (ICP) monitoring regarding the perioperative management of patients with severe traumatic brain injury (sTBI). This was a cohort study performed between Jan 2013 and Jan 2016 and included all patients with sTBI. All patients were split into ICP monitoring and non-ICP monitoring groups. The primary outcomes were in-hospital mortality and Glasgow Outcome Scale (GOS) scores 6 months after injury, whereas the secondary outcomes include rate of successful nonsurgical treatment, rate of decompression craniotomy (DC), the length of stay in the ICU, and the hospital and medical expenses. This retrospective analysis included 246 ICP monitoring sTBI patients and 695 without ICP monitoring sTBI patients. No significant difference between groups regarding patient demographics. All patients underwent a GOS assessment 6 months after surgery. Compared to the non-ICP monitoring group, a lower in-hospital mortality (20.3% vs 30.2%, P < 0.01) and better GOS scores after 6 months (3.3 ±â€Š1.6 vs 2.9 ±â€Š1.6, P < 0.05) with ICP monitoring. In addition, patients in the ICP monitoring group had a lower craniotomy rate (41.1% vs 50.9%, P < 0.01) and a lower DC rate (41.6% vs 55.9%, P < 0.05) than those in the non-ICP monitoring group. ICU length of stay (12.4 ±â€Š4.0 days vs 10.2 ±â€Š4.8 days, P < 0.01) was shorter in the non-ICP monitoring group, but it had no difference between 2 groups on total length of hospital stay (22.9 ±â€Š13.6 days vs 24.6 ±â€Š13.6 days, P = 0.108); Furthermore, the medical expenses were significantly higher in the non-ICP monitoring group than the ICP monitoring group (11.5 ±â€Š7.2 vs 13.3 ±â€Š9.1, P < 0.01). Intracranial pressure monitoring has beneficial effects for sTBI during the perioperative period. It can reduce the in-hospital mortality and DC rate and also can improve the 6-month outcomes. However, this was a single institution and observational study, well-designed, multicenter, randomized control trials are needed to evaluate the effects of ICP monitoring for perioperative sTBI patients.


Assuntos
Lesões Encefálicas Traumáticas/fisiopatologia , Pressão Intracraniana , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/cirurgia , Criança , Craniectomia Descompressiva , Feminino , Escala de Resultado de Glasgow , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Período Perioperatório , Estudos Retrospectivos , Adulto Jovem
8.
World Neurosurg ; 131: e312-e320, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31351936

RESUMO

OBJECTIVE: The use of autologous bone for cranioplasty offers superior cosmesis and cost-effectiveness compared with synthetic materials. The choice between 2 common autograft storage mechanisms (subcutaneous vs. frozen) remains controversial and dictated by surgeon preference. We compared surgical outcomes after autologous bone cranioplasty between patients with cryopreserved and subcutaneously stored autografts. METHODS: Ten-year retrospective comparative analysis of patients undergoing cranioplasty with autologous bone stored subcutaneously or frozen at a tertiary academic medical center. RESULTS: Ninety-four patients were studied, with 34 (36.2%) bone flaps stored subcutaneously and 59 (62.8%) frozen. The 2 groups were similar in demographics, comorbidities, and craniectomy indication, with only body mass index and race differing statistically. The mean operation time was greater within the subcutaneous group (P < 0.001), which also had a greater number of ventriculoperitoneal shunt (VPS) placements (P = 0.02). There were no significant differences in complications, readmissions, unplanned reoperations, or length of stay between the 2 groups. VPS placement during cranioplasty increased length of stay (P < 0.001), and placement prior to cranioplasty increased both length of stay (P = 0.009) and incidence of hospital-acquired infection (P = 0.03). CONCLUSIONS: Subcutaneous and frozen storage of autologous bone result in similar surgical risk profiles. Cryopreservation may be preferred because of shorter operation time and avoidance of complications with the abdominal pocket, whereas the portability of subcutaneous storage remains favorable for patients undergoing cranioplasty at a different institution. VPS placement prior to cranioplasty should be avoided, if possible, due to the increased risk of hospital-acquired infection.


Assuntos
Abdome/cirurgia , Transplante Ósseo/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Crânio/transplante , Tela Subcutânea/cirurgia , Retalhos Cirúrgicos , Preservação de Tecido/métodos , Adulto , Osso e Ossos , Edema Encefálico/cirurgia , Lesões Encefálicas Traumáticas/cirurgia , Craniotomia , Infecção Hospitalar/epidemiologia , Criopreservação , Feminino , Humanos , Hemorragias Intracranianas/cirurgia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Acidente Vascular Cerebral/cirurgia , Transplante Autólogo/métodos , Derivação Ventriculoperitoneal/estatística & dados numéricos
9.
BMC Infect Dis ; 19(1): 648, 2019 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-31331282

RESUMO

BACKGROUND: We report a rare case of anaerobic vertebral osteomyelitis associated with surgical tracheotomy which has never been reported to the best of our knowledge. CASE PRESENTATION: A healthy 39-year-old man was admitted to intensive care for a severe brain trauma injury where a surgical tracheotomy was performed. He was discharged to a rehabilitation centre after 54 days hospital stay. During rehabilitation, he developed progressive and febrile tetraplegia associated with cervical pain, requiring an intensive care readmission. A polymicrobial anaerobic bloodstream infection was revealed and magnetic resonance imaging diagnosed cervical vertebral osteomyelitis. Both the type of anaerobic micro-organisms found and the timing of the symptoms strongly suggest that the surgical tracheotomy was responsible for this rare case of cervical vertebral osteomyelitis. The patient was successfully treated by a prolonged antimicrobial therapy and by surgical laminectomy. CONCLUSIONS: Tracheotomy may generate anaerobic bacteraemia and related osteomyelitis in the specific setting of severe trauma patients. Clinicians should consider anaerobic vertebral osteomyelitis when they are confronted with a febrile tetraplegia after tracheotomy.


Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Osteomielite/microbiologia , Traqueotomia/efeitos adversos , Adulto , Bactérias Anaeróbias/patogenicidade , Infecções Bacterianas/microbiologia , Lesões Encefálicas Traumáticas/cirurgia , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/microbiologia , Humanos , Imagem por Ressonância Magnética , Masculino , Osteomielite/diagnóstico , Osteomielite/tratamento farmacológico
12.
Pediatr Neurosurg ; 54(4): 237-244, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31288223

RESUMO

BACKGROUND: Extradural hematoma (EDH) is one of the most common causes of mortality and morbidity after traumatic brain injury in pediatric patients. Early surgical intervention in these patients produces excellent results. OBJECTIVE: We reviewed surgical experience at our center, examining and presenting symptomatology and outcome analysis. MATERIALS AND METHODS: A retrospective study of 228 pediatric patients of EDH from July 2007 to August 2017 was performed. Patients were evaluated in terms of demographic profile, clinical features, pupillary size and reaction, computed tomography findings, operative measures, and several other parameters. Neurological status was assessed using motor component (M) of Glasgow Coma Scale score. Best motor response was considered as a criterion to classify severity of traumatic brain injury and for the assessment of outcome. RESULTS: Most of the patients were in the age group of 13-18 years (n = 122, 53.5%). Majority of them were male (n = 182, 79.8%). The commonest mode of injury was fall from height (n = 116, 50.9%) followed by road traffic accident (n = 92, 40.4%). Most common site of hematoma was frontal region (n = 66, 28.9%) followed by parietal region (n = 54, 23.7%). The volume of hematoma was between 30 and 50 mL in majority of the patients (n = 186, 81.6%), and most of the patients had a motor responses of M5 (n = 88, 38.6%) and M6 (n = 108, 47.4%). The association between hematoma site and volume was not significant (χ2 = 5.910, p = 0.749), whereas statistically significant association was noted between volume of hematoma and motor response (χ2 = 93.468, p ≤ 0.001), volume and age (χ2 = 7.380, p ≤ 0.05), and volume to time between trauma and surgery (χ2 = 8.469, p ≤ 0.05). Maximum mortality was in patients of low motor (M1-M3) response and who were operated 24 h after injury. CONCLUSION: Mortality in patients of EDH can be significantly reduced with gratifying results if operated early. Best motor response at presentation, pupillary abnormalities, time between injury to surgery, and location of hematoma have been identified as the important factors determining outcome in patients of EDH.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Hematoma Epidural Craniano , Procedimentos Neurocirúrgicos , Acidentes por Quedas , Adolescente , Feminino , Escala de Coma de Glasgow , Hematoma Epidural Craniano/mortalidade , Hematoma Epidural Craniano/cirurgia , Humanos , Masculino , Estudos Retrospectivos , Centros de Atenção Terciária , Fatores de Tempo
13.
J Craniofac Surg ; 30(7): 2168-2170, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31274818

RESUMO

BACKGROUND: Tracheotomy has played an important role in the treatment of patients with severe traumatic brain injury (TBI), the appropriate tracheotomy time will affect the prognosis of patients. However, the timing of tracheostomy after severe TBI remains controversial. To find the optimal time for tracheostomy, the authors compared the effects of early tracheostomy (ET) versus late tracheostomy (LT) on TBI-related outcomes and prognosis. METHODS: The clinical data of 98 patients with severe TBI treated by tracheotomy at NICU, First Affiliated Hospital of Xi'an Medical University, January 2017 to January 2018, were analyzed retrospectively. According to the time of the tracheotomy during the treatment, the patients were divided into ET group (after admission <3 days) and LT group (>3 days after admission). The NICU stay, hospital stay, long duration of antibiotic use, pneumonia rates, mortality rates, improvement of nerve function, complications of tracheotomy, and treatment cost were compared between the 2 groups. RESULTS: The NICU stay, hospitalization stay, and antibiotic use time of patients in the ET group were shorter than those in the LT group (P < 0.05). The pneumonia rates and the cost of hospitalization in the ET group were lower than those in the LT group (P < 0.05). The complications of the tracheostomy, mortality, and neurologic function improvements were not statistically significant in the 2 groups (P > 0.05). CONCLUSION: For severe TBI, ET can reduce the NICU stay, hospitalization stay, length of antibiotic use, and reduce the incidence rates of pneumonia and the cost of hospitalization compared with LT, but there is no significant improvement in the mortality rates and neurologic function of patients during hospitalization.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonia , Prognóstico , Estudos Retrospectivos , Fatores de Tempo , Traqueostomia/efeitos adversos , Adulto Jovem
14.
Am Surg ; 85(4): 370-375, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-31043197

RESUMO

The effect of timing in patients requiring tracheostomy varies in the literature. The purpose of this study was to evaluate the impact of early tracheostomy on outcomes in trauma patients with and without traumatic brain injury (TBI). This study is a four-year review of trauma patients undergoing tracheostomy. Patients were divided into two groups based on TBI/non-TBI. Each group was divided into three subgroups based on tracheostomy timing: zero to three days, four to seven days, and greater than seven days postadmission. TBI patients were stratified by the Glasgow Coma Scale (GCS), and non-TBI patients were stratified by the Injury Severity Score (ISS). The primary outcome was ventilator-free days (VFDs). Significance was defined as P < 0.05. Two hundred eighty-nine trauma patients met the study criteria: 151 had TBI (55.2%) versus 138 (47.8%) non-TBI. There were no significant differences in demographics within and between groups. In TBI patients, statistically significant increases in VFDs were observed with GCS 13 to 15 for tracheostomies performed in four to seven versus greater than seven days (P = 0.005). For GCS <8 and 8 to 12, there were significant increases in VFDs for tracheostomies performed at days 1 to 3 and 4 to 7 versus greater than seven days (P ≪ 0.05 for both). For non-TBI tracheostomies, only ISS ≥ 25 with tracheostomies performed at zero to three days versus greater than seven days was associated with improved VFDs. Early tracheostomies in TBI patients were associated with improved VFDs. In trauma patients with no TBI, early tracheostomy was associated with improved VFDs only in patients with ISS ≥ 25. Future research studies should investigate reasons TBI and non-TBI patients may differ.


Assuntos
Traqueostomia/métodos , Ferimentos e Lesões/cirurgia , Adulto , Lesões Encefálicas Traumáticas/cirurgia , Estudos de Casos e Controles , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
15.
World Neurosurg ; 129: e56-e62, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31054345

RESUMO

BACKGROUND: Severe traumatic brain injury (TBI) is the most common cause of disability in children. Refractory increased intracranial pressure can be a therapeutic challenge. Decompressive craniectomy can be proposed when medical management is insufficient, but its place is not clearly defined in guidelines. The aim of this study was to identify prognostic factors in children with TBI. METHODS: We performed a retrospective, multicenter study to analyze long-term outcomes of 150 children with severe TBI treated by decompressive craniectomy and to identify prognostic factors. RESULTS: A satisfactory neurologic evolution (represented by a King's Outcome Scale for Childhood Head Injury score >3) was observed in 62% of children with a mean follow-up of 3.5 years. Mortality rate was 17%. Prognostic factors associated with outcome were age, initial Glasgow Coma Scale score, presence of mydriasis, neuromonitoring values (maximal intracranial pressure >30 mm Hg), and radiologic findings (Rotterdam score ≥4). CONCLUSIONS: This study in a large population confirms that children with severe TBI treated by decompressive craniectomy can achieve a good neurologic outcome. Further studies are needed to clarify the use of this surgery in the management of children with severe TBI.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento
16.
World Neurosurg ; 127: e1166-e1171, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30995562

RESUMO

BACKGROUND: Hydrocephalus is a common complication following decompressive craniectomy. Ventriculoperitoneal shunt (VPS) is required for some patients before receiving a cranioplasty (CP). The presence of a VPS is regarded as a risk factor for overall CP complications. METHODS: A retrospective survey was conducted on 176 patients with traumatic brain injury who underwent late (>3 months) titanium CP (Ti-CP) in our hospital from April 2014 to July 2018. Thirteen patients (7.4%) had preoperative VPS. Propensity score matching was performed for these 13 patients with a ratio of 1:5. A total of 78 patients were selected. Preoperative clinical parameters and postoperative complications were analyzed. The period of postoperative follow-up ranged from 3 to 63 months (mean 21.3 ± 17.0 months). RESULTS: The overall complication rate was greater in the VPS group (P = 0.010). These patients were more likely to develop a sunken skin flap (P < 0.001). The rate of postoperative cerebral hemorrhage was greater in the VPS group. Logistic analysis showed that preoperative VPS was an independent risk factor for postoperative extradural collection (odds ratio 17.714, P < 0.001). VPS was not related to postoperative infection and seizure. Postoperative drainage duration longer than 2.5 days significantly increased the risk of postoperative infection (odds ratio 7.715, P = 0.023). CONCLUSIONS: The presence of a VPS significantly increased the risk of extradural collection in patients with traumatic brain injury who underwent late Ti-CP. It also was related to postoperative hemorrhage. The sunken skin flap in patients with VPS increased surgical difficulty and the likelihood of extradural accumulation. Preoperative VPS was not related to postoperative infection and seizure in Ti-CP.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/efeitos adversos , Complicações Pós-Operatórias/etiologia , Titânio/efeitos adversos , Derivação Ventriculoperitoneal/efeitos adversos , Adolescente , Adulto , Idoso , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Craniectomia Descompressiva/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Derivação Ventriculoperitoneal/tendências , Adulto Jovem
17.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 30(2): 77-80, mar.-abr. 2019.
Artigo em Espanhol | IBECS | ID: ibc-182005

RESUMO

El traumatismo craneoencefálico (TCE) representa una cantidad significativa de muertes y discapacidad a nivel mundial, afectando la mayor parte de esta carga a los países con ingresos medios y bajos. El estudio GNOS es un estudio internacional multicéntrico de cohorte prospectiva. Es el primer estudio neuroquirúrgico global que tiene como objetivo proporcionar una imagen completa del manejo y los resultados de los pacientes que han sido tratados mediante cirugía urgente por TCE a nivel mundial


Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. The GNOS is a multi-centre international, prospective cohort study. This study is the first global neurosurgical study that aims to provide a comprehensive picture of the management and outcomes of patients undergoing emergency surgery for TBI worldwide


Assuntos
Humanos , Lesões Encefálicas Traumáticas/cirurgia , Neurocirurgia/tendências , Prognóstico , Projetos de Pesquisa , Estudos Prospectivos , Procedimentos Neurocirúrgicos/mortalidade , Complicações Pós-Operatórias
18.
BMC Surg ; 19(1): 26, 2019 Feb 27.
Artigo em Inglês | MEDLINE | ID: mdl-30813919

RESUMO

BACKGROUND: Subdural effusion with hydrocephalus (SDEH) is a rare complication of traumatic brain injury, especially following decompressive craniectomy (DC) for posttraumatic cerebral infarction. The diagnosis and treatment are still difficult and controversial for neurosurgeons. CASE PRESENTATION: A 45-year-old man developed traumatic cerebral infarction after traumatic brain injury and underwent DC because of the mass effect of cerebral infarction. Unfortunately, the complications of traumatic subdural effusion (SDE) and hydrocephalus occurred in succession following DC. Burr-hole drainage and subdural peritoneal shunt were performed in sequence because of the mass effect of SDE, which only temporarily improved the symptoms of the patient. Cranioplasty and ventriculoperitoneal shunt were performed ultimately, after which SDE disappeared completely. However, the patient remains severely disabled, with a Glasgow Outcome Scale of 3. CONCLUSIONS: It is important for neurosurgeons to consider the presence of accompanying hydrocephalus when treating patients with SDE. Once the diagnosis of SDEH is established and the SDE has no mass effect, timely ventriculoperitoneal shunt may be needed to avoid multiple surgical procedures, which is a safe and effective surgical method to treat SDEH.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/efeitos adversos , Hidrocefalia/cirurgia , Derrame Subdural/cirurgia , Lesões Encefálicas Traumáticas/complicações , Infarto Cerebral/etiologia , Drenagem , Humanos , Hidrocefalia/etiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Derrame Subdural/etiologia , Resultado do Tratamento , Derivação Ventriculoperitoneal
19.
World J Emerg Surg ; 14: 9, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30873217

RESUMO

Background: Traumatic brain injury (TBI) is a global health problem. Extracranial hemorrhagic lesions needing emergency surgery adversely affect the outcome of TBI. We conducted an international survey regarding the acute phase management practices in TBI polytrauma patients. Methods: A questionnaire was available on the World Society of Emergency Surgery website between December 2017 and February 2018. The main endpoints were the evaluation of (1) intracranial pressure (ICP) monitoring during extracranial emergency surgery (EES), (2) hemodynamic management without ICP monitoring during EES, (3) coagulation management, and (4) utilization of simultaneous multisystem surgery (SMS). Results: The respondents were 122 representing 105 trauma centers worldwide. ICP monitoring was utilized in 10-30% of patients at risk of intracranial hypertension (IH) undergoing EES from about a third of the respondents [n = 35 (29%)]. The respondents reported that the safest values of systolic blood pressure during EES in patients at risk of IH were 90-100 mmHg [n = 35 (29%)] and 100-110 mmHg [n = 35 (29%)]. The safest values of mean arterial pressure during EES in patients at risk of IH were > 70 mmHg [n = 44 (36%)] and > 80 mmHg [n = 32 (26%)]. Regarding ICP placement, a large percentage of respondents considered a platelet (PLT) count > 50,000/mm3 [n = 57 (47%)] and a prothrombin time (PT)/activated partial thromboplastin time (aPTT) < 1.5 times the normal control [n = 73 (60%)] to be the safest parameters. For craniotomy, the majority of respondents considered PLT count > 100,000/mm3 [n = 67 (55%)] and a PT/aPTT < 1.5 times the normal control [n = 76 (62%)] to be the safest parameters. Almost half of the respondents [n = 53 (43%)], reported that they transfused red blood cells (RBCs)/plasma (P)/PLTs at a ratio of 1/1/1 in TBI polytrauma patients. SMS was performed in 5-19% of patients, requiring both an emergency neurosurgical operation and EES, by almost half of the respondents [n = 49 (40%)]. Conclusions: A great variability in practices during the acute phase management of polytrauma patients with severe TBI was identified. These findings may be helpful for future investigations and educational purposes.


Assuntos
Lesões Encefálicas Traumáticas/cirurgia , Procedimentos Neurocirúrgicos/métodos , Ferimentos e Lesões/cirurgia , Pressão Venosa Central/fisiologia , Gerenciamento Clínico , Escala de Coma de Glasgow , Humanos , Internacionalidade , Hipertensão Intracraniana/prevenção & controle , Pressão Intracraniana/fisiologia , Monitorização Fisiológica/métodos , Tempo de Protrombina/métodos , Inquéritos e Questionários
20.
World Neurosurg ; 126: e232-e240, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30825623

RESUMO

BACKGROUND: In Cambodia, the most common victims of traumatic brain injury (TBI) are men 20-30 years of age involved in motor vehicle collision. Secondary injury sustained by these patients occurs during the time period between initial insult and hospital admission. Strengthening prehospital systems for TBI in low- and middle-income countries (LMICs) such as Cambodia is therefore a key element of the development agenda for universal health equity. We report a retrospective analysis of the relationship between prehospital delays and TBI outcomes among patients from a large government hospital in Cambodia. METHODS: Data were collected from 3476 patients with TBI admitted to a major government hospital in Phnom Penh, Cambodia, from June 2013 to June 2018. Patients with missing data or those admitted >8 hours postinjury were excluded. Statistical analyses examined associations between injury-to-admission delay (IAD) and outcomes such as Glasgow Outcome Scale (GOS) score and length of stay (LOS). RESULTS: A total of 2125 patients with TBI (76.85% men) were included. The median age was 27 years (interquartile range, 22-37 years). Injury severity at presentation included 1406 mild (66%), 464 moderate (22%), and 240 severe cases (11%). No Glasgow Coma Scale (GCS) data were available for 15 patients (1%). We found an inverse relationship between IAD and GOS score, most evidently for mild and moderate TBI (n = 1870; 88%). Regression analysis revealed a marked decrease in GOS score at the IAD >4-hour threshold. Each 30-minute delay in IAD was correlated with >2-hour increase in LOS for mild (P < 0.001) and moderate TBI (P < 0.001). CONCLUSIONS: In a retrospective cohort of >2000 patients with TBI from Cambodia, we found that increasing IAD was associated with worsening outcome, especially beyond the 4-hour threshold. These data should inform development of prehospital guidelines for TBI care in LMICs.


Assuntos
Lesões Encefálicas Traumáticas/terapia , Tempo para o Tratamento , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/cirurgia , Camboja/epidemiologia , Estudos de Coortes , Serviços Médicos de Emergência , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
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