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1.
N Engl J Med ; 375(12): 1119-30, 2016 09 22.
Artículo en Inglés | MEDLINE | ID: mdl-27602507

RESUMEN

BACKGROUND: The effect of decompressive craniectomy on clinical outcomes in patients with refractory traumatic intracranial hypertension remains unclear. METHODS: From 2004 through 2014, we randomly assigned 408 patients, 10 to 65 years of age, with traumatic brain injury and refractory elevated intracranial pressure (>25 mm Hg) to undergo decompressive craniectomy or receive ongoing medical care. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOS-E) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 6 months. The primary-outcome measure was analyzed with an ordinal method based on the proportional-odds model. If the model was rejected, that would indicate a significant difference in the GOS-E distribution, and results would be reported descriptively. RESULTS: The GOS-E distribution differed between the two groups (P<0.001). The proportional-odds assumption was rejected, and therefore results are reported descriptively. At 6 months, the GOS-E distributions were as follows: death, 26.9% among 201 patients in the surgical group versus 48.9% among 188 patients in the medical group; vegetative state, 8.5% versus 2.1%; lower severe disability (dependent on others for care), 21.9% versus 14.4%; upper severe disability (independent at home), 15.4% versus 8.0%; moderate disability, 23.4% versus 19.7%; and good recovery, 4.0% versus 6.9%. At 12 months, the GOS-E distributions were as follows: death, 30.4% among 194 surgical patients versus 52.0% among 179 medical patients; vegetative state, 6.2% versus 1.7%; lower severe disability, 18.0% versus 14.0%; upper severe disability, 13.4% versus 3.9%; moderate disability, 22.2% versus 20.1%; and good recovery, 9.8% versus 8.4%. Surgical patients had fewer hours than medical patients with intracranial pressure above 25 mm Hg after randomization (median, 5.0 vs. 17.0 hours; P<0.001) but had a higher rate of adverse events (16.3% vs. 9.2%, P=0.03). CONCLUSIONS: At 6 months, decompressive craniectomy in patients with traumatic brain injury and refractory intracranial hypertension resulted in lower mortality and higher rates of vegetative state, lower severe disability, and upper severe disability than medical care. The rates of moderate disability and good recovery were similar in the two groups. (Funded by the Medical Research Council and others; RESCUEicp Current Controlled Trials number, ISRCTN66202560 .).


Asunto(s)
Lesiones Encefálicas/complicaciones , Craniectomía Descompresiva , Hipertensión Intracraneal/cirugía , Adolescente , Adulto , Anciano , Lesiones Encefálicas/terapia , Niño , Terapia Combinada , Craniectomía Descompresiva/efectos adversos , Personas con Discapacidad , Femenino , Escala de Coma de Glasgow , Humanos , Hipertensión Intracraneal/tratamiento farmacológico , Hipertensión Intracraneal/etiología , Hipertensión Intracraneal/mortalidad , Masculino , Persona de Mediana Edad , Estado Vegetativo Persistente/epidemiología , Estado Vegetativo Persistente/etiología , Resultado del Tratamiento , Adulto Joven
2.
JAMA Neurol ; 79(7): 664-671, 2022 07 01.
Artículo en Inglés | MEDLINE | ID: mdl-35666526

RESUMEN

Importance: Trials often assess primary outcomes of traumatic brain injury at 6 months. Longer-term data are needed to assess outcomes for patients receiving surgical vs medical treatment for traumatic intracranial hypertension. Objective: To evaluate 24-month outcomes for patients with traumatic intracranial hypertension treated with decompressive craniectomy or standard medical care. Design, Setting, and Participants: Prespecified secondary analysis of the Randomized Evaluation of Surgery With Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) randomized clinical trial data was performed for patients with traumatic intracranial hypertension (>25 mm Hg) from 52 centers in 20 countries. Enrollment occurred between January 2004 and March 2014. Data were analyzed between 2018 and 2021. Eligibility criteria were age 10 to 65 years, traumatic brain injury (confirmed via computed tomography), intracranial pressure monitoring, and sustained and refractory elevated intracranial pressure for 1 to 12 hours despite pressure-controlling measures. Exclusion criteria were bilateral fixed and dilated pupils, bleeding diathesis, or unsurvivable injury. Interventions: Patients were randomly assigned 1:1 to receive a decompressive craniectomy with standard care (surgical group) or to ongoing medical treatment with the option to add barbiturate infusion (medical group). Main Outcomes and Measures: The primary outcome was measured with the 8-point Extended Glasgow Outcome Scale (1 indicates death and 8 denotes upper good recovery), and the 6- to 24-month outcome trajectory was examined. Results: This study enrolled 408 patients: 206 in the surgical group and 202 in the medical group. The mean (SD) age was 32.3 (13.2) and 34.8 (13.7) years, respectively, and the study population was predominantly male (165 [81.7%] and 156 [80.0%], respectively). At 24 months, patients in the surgical group had reduced mortality (61 [33.5%] vs 94 [54.0%]; absolute difference, -20.5 [95% CI, -30.8 to -10.2]) and higher rates of vegetative state (absolute difference, 4.3 [95% CI, 0.0 to 8.6]), lower or upper moderate disability (4.7 [-0.9 to 10.3] vs 2.8 [-4.2 to 9.8]), and lower or upper severe disability (2.2 [-5.4 to 9.8] vs 6.5 [1.8 to 11.2]; χ27 = 24.20, P = .001). For every 100 individuals treated surgically, 21 additional patients survived at 24 months; 4 were in a vegetative state, 2 had lower and 7 had upper severe disability, and 5 had lower and 3 had upper moderate disability, respectively. Rates of lower and upper good recovery were similar for the surgical and medical groups (20 [11.0%] vs 19 [10.9%]), and significant differences in net improvement (≥1 grade) were observed between 6 and 24 months (55 [30.0%] vs 25 [14.0%]; χ22 = 13.27, P = .001). Conclusions and Relevance: At 24 months, patients with surgically treated posttraumatic refractory intracranial hypertension had a sustained reduction in mortality and higher rates of vegetative state, severe disability, and moderate disability. Patients in the surgical group were more likely to improve over time vs patients in the medical group. Trial Registration: ISRCTN Identifier: 66202560.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Lesiones Encefálicas , Craniectomía Descompresiva , Hipertensión Intracraneal , Adolescente , Adulto , Anciano , Lesiones Encefálicas/complicaciones , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Lesiones Traumáticas del Encéfalo/cirugía , Niño , Craniectomía Descompresiva/métodos , Femenino , Humanos , Hipertensión Intracraneal/complicaciones , Hipertensión Intracraneal/cirugía , Masculino , Persona de Mediana Edad , Estado Vegetativo Persistente , Resultado del Tratamiento , Adulto Joven
3.
Surg Neurol ; 71(4): 493-5, 2009 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-18291468

RESUMEN

BACKGROUND: Giant cell reparative granuloma is a condition commonly found in the facial bones. It has been reported in the skull bones, predominantly the bones comprising the skull base. Giant cell reparative granuloma of the cranial vault is exceedingly rare. Its distinction from a neoplastic lesion is difficult clinically and radiologically. CASE DESCRIPTION: Only the third case of a GCRG of the skull vault, the first in an adult, is described. Its pathophysiology and differential diagnoses influencing management are discussed. CONCLUSION: It is not possible to diagnose this condition definitively on a clinical or radiologic basis, and given its differential diagnoses, an excision biopsy should be offered.


Asunto(s)
Granuloma de Células Gigantes/patología , Traumatismos Cerrados de la Cabeza/complicaciones , Hueso Parietal/patología , Cráneo/patología , Adulto , Craneotomía/métodos , Duramadre/patología , Duramadre/cirugía , Femenino , Granuloma de Células Gigantes/etiología , Granuloma de Células Gigantes/cirugía , Humanos , Hueso Parietal/diagnóstico por imagen , Hueso Parietal/lesiones , Prótesis e Implantes , Radiografía , Procedimientos de Cirugía Plástica/instrumentación , Procedimientos de Cirugía Plástica/métodos , Cráneo/diagnóstico por imagen , Cráneo/lesiones , Titanio/uso terapéutico , Resultado del Tratamiento
4.
Interv Neuroradiol ; 25(5): 530-538, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-30931672

RESUMEN

In this report, we present two cases using a novel flow diverter, the Silk Vista Baby, to treat aneurysms successfully, both ruptured and unruptured, that would have been difficult to treat using alternative flow diverters. We describe the clinical and radiological features, outcome and the unique features of the Silk Vista Baby flow diverter.


Asunto(s)
Aneurisma Roto/cirugía , Prótesis Vascular , Stents , Hemorragia Subaracnoidea/cirugía , Adulto , Aneurisma Roto/diagnóstico por imagen , Angiografía de Substracción Digital , Implantación de Prótesis Vascular , Angiografía por Tomografía Computarizada , Embolización Terapéutica/métodos , Procedimientos Endovasculares/métodos , Femenino , Humanos , Hemorragia Subaracnoidea/diagnóstico por imagen , Resultado del Tratamiento
5.
Interv Neuroradiol ; 25(3): 310-314, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-30764685

RESUMEN

Ruptured arteriovenous malformations are a frequently encountered pathology with significant associated morbidity and mortality. Identifying and securing the rupture point is mandatory; however, this can often be difficult. Black blood vessel wall magnetic resonance imaging is a promising technique for identifying ruptured saccular aneurysms and has been used in cases of multiple aneurysms. Here we describe a case of using this imaging technique to identify the rupture point in a ruptured arteriovenous malformation with histopathological correlation.


Asunto(s)
Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/etiología , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/etiología , Malformaciones Arteriovenosas Intracraneales/complicaciones , Malformaciones Arteriovenosas Intracraneales/diagnóstico por imagen , Adulto , Aneurisma Roto/cirugía , Angiografía Cerebral , Embolización Terapéutica/métodos , Femenino , Humanos , Aneurisma Intracraneal/cirugía , Malformaciones Arteriovenosas Intracraneales/cirugía , Angiografía por Resonancia Magnética , Tomografía Computarizada por Rayos X , Resultado del Tratamiento
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