Jiang-Biao Gong

A prospective study of early versus late craniectomy after traumatic brain injury

Background: Decompressive craniectomy is an important method for managing traumatic brain injury (TBI). At present, controversies about this procedure exist, especially about the optimum operative time for patients with TBI. Methods: A prospective study was performed at the First Affiliated Hospital, College of Medicine, Zhejiang University. From January 2008 to December 2009, 25 patients who underwent early decompressive craniectomy were included in the study group, and 19 patients who underwent “late” decompressive craniectomy as a second-tier therapy for intracranial hypertension were included as a comparison group. Results: The 30-day mortality after the operation was 16% in the study group. The overall mortality rate was 20% at the 6-month follow-up. A total of 52% of the patients (13 patients) had good outcomes, and 7 patients remained in a severely disabled or vegetative state. In the comparison group, 4 patients died, and 12 had good outcomes at the 6-month follow-up. The remaining 3 patients had poor outcomes. The study group was well matched with the comparison group. However, the outcomes in the study group were not better than those in the comparison group, as evaluated by the 6-month GOS score. Conclusion: Early decompressive craniectomy as a first-tier therapy for intracranial hypertension did not improve patient outcome when compared with “late” decompressive craniectomy for managing TBI.

The impact of cranioplasty on cerebral blood perfusion in patients treated with decompressive craniectomy for severe traumatic brain injury

Abstract Background: A large cranial defect following decompressive craniectomy (DC) is a common sequela in patients with severe traumatic brain injury (TBI). Such a defect can cause severe disturbance of cerebral blood flow (CBF) regulation. This study investigated the impact of cranioplasty on CBF in these patients. Methods: Patients who underwent DC and secondary cranioplasty were prospectively studied for a severe TBI. CT perfusion was used to measure CBF before and after cranioplasty. The basal ganglia, parietal lobe and occipital lobe on the decompressed side were chosen as zones of interest for CBF evaluation. Results: Nine patients representing nine cranioplasty procedures were included in the study. Before cranioplasty, CBF on the decompressed side was lower than that on the contralateral side. During the early stage (10 days) after cranioplasty, CBF on the decompressed side was increased and this increase was significant in the parietal and occipital lobe. CBF was also increased on the contralateral side. In addition, the difference in CBF between the contralateral side and the decompressed side was reduced after cranioplasty. Further, the CT perfusion showed that the CBFs decreased again 3 months post-cranioplasty among four cases, but was still higher than those before cranioplasty. Conclusions: This study indicates that cranioplasty may increase CBF and benefit the recovery in patients with DC for TBI.

Shunt implantation in a special sub-group of post-traumatic hydrocephalus—patients have normal intracranial pressure without clinical representations of hydrocephalus

Background: Post-traumatic hydrocephalus (PTH) is a frequent complication secondary to traumatic brain injury (TBI) and controversy remains over whether to perform a shunt placement for patients with normal pressure hydrocephalus when the patient is too injured to display symptoms or has atypical symptoms. Method: A hospital-based retrospective study was performed in patients who developed normal pressure hydrocephalus, without atypical symptoms, from January 2004 to June 2007. Information regarding patients’ demographics, TBI, hydrocephalus and outcome was collected. Results: A total of 31 patients were involved in this study. At the 12-month follow-up, 20 patients (64.5%) showed clear improvement. Among the 10 patients who developed PTH after decompressive craniectomy, cranioplasty was performed after shunt implantation and clinical improvement was observed in nine patients. Additionally, in this series, the patients’ age and the severity of hydrocephalus, assessed by CT imaging before shunt placement, significantly correlated with improvement. Conclusion: Although the effect was not definitively established, many patients in the sub-group of PTH patients described here would benefit from shunt placement, especially when they simultaneously have large cranial defects after surgical decompression and underwent cranioplasties after shunt placement. Additionally, younger patients and those with less severe hydrocephalus before shunt placement may expect a better outcome after shunt placement.

Subdural effusion secondary to decompressive craniectomy in patients with severe traumatic brain injury

Dear Editor, Firstly, thanks for the attention on our study. Nowadays, decompressive craniectomy is an important method for the management of patients with severe head trauma, and apparently the prevention and management of complications are crucial parts of this surgical method. Actually, a great part of these complications would be secondary to head trauma or craniotomy as well, including subdural effusion, post-traumatic hydrocephalus, intracranial infection, cerebrospinal fluid leakage, intracranial rehemorrhage, and epilepsy. Subdural effusion is a complication that could be secondary to both head trauma and craniotomy. The incidence rate of subdural effusion in head trauma was between 7 and 12% [3], and that after decompressive craniectomy was between 21 and 50% reportedly [1, 2, 4, 5]. In our series, this rate was 21.3%. We agree on the explanation of the reasons for the high incidence of subdural effusion secondary to decompressive craniectomy from Dr. Cumher Kilincer. However, here we want to emphasize another reason for the development of subdural effusion. We have treated a patient who was transferred to our hospital 2 months after surgical decompression for severe head trauma. The local hospital sent him to our hospital for deterioration of consciousness, and the CT scan disclosed subdural effusion contralateral to the decompressive side (Fig. 1). We reviewed the patient’s medical record, and it was found that though the brain edema was not disclosed from the CT on the late phase of head trauma the treatment of dehydration was still lasted. The excessive dehydration was believed to be an important reason for the development of subdural effusion. After stopping the dehydration, this patient recovered under conservative treatment and the CT approved the resolution of effusion. Such a case may not be the only one, and the development

Therapeutic effect of erythropoietin in patients with traumatic brain injury: a meta-analysis of randomized controlled trials

OBJECTIVE Erythropoietin (EPO) exerts a neuroprotective effect in animal models of traumatic brain injury (TBI). However, its effectiveness in human patients with TBI is unclear. In this study, the authors conducted the first meta-analysis to assess the effectiveness and safety of EPO in patients with TBI. METHODS In December 2015, a systematic search was performed of PubMed, Web of Science, MEDLINE, Embase, the Cochrane Library databases, and Google Scholar. Only English-language publications of randomized controlled trials (RCTs) using EPO in patients with TBI were selected for analysis. The assessed outcomes included mortality, favorable neurological outcome, hospital stay, and associated adverse effects. Continuous variables were presented as mean difference (MD) with a 95% confidence interval (CI). Dichotomous variables were presented as risk ratio (RR) or risk difference (RD) with a 95% CI. Statistical heterogeneity was examined using both I2 and chi-square tests. RESULTS Of the 346 studies identified in the search, 5 RCTs involving 915 patients met the inclusion criteria. The overall results demonstrated that EPO significantly reduced mortality (RR 0.69, 95% CI 0.49-0.96, p = 0.03) and shortened the hospitalization time (MD -7.59, 95% CI -9.71 to -5.46, p < 0.0001) for patients with TBI. Pooled results of favorable outcome (RR 1.00, 95% CI 0.88-1.15, p = 0.97) and deep vein thrombosis (DVT; RD 0.00, 95% CI -0.05 to 0.05, p = 1.00) did not show a significant difference. CONCLUSIONS The authors suggested that EPO is beneficial for patients with TBI in terms of reducing mortality and shortening hospitalization time without increasing the risk of DVT. However, its effect on improving favorable neurological outcomes did not reach statistical significance. Therefore, more well-designed RCTs are necessary to ascertain the optimum dosage and time window of EPO treatment for patients with TBI.

Endoscope‐assisted supraorbital keyhole approach for the resection of benign tumors of the sellar region

The objective of the study was to evaluate the effectiveness of the supraorbital “keyhole” approach with endoscope assistance in surgical treatment of benign tumors around the sellar region. Thirty‐five patients, including 19 pituitary tumors, 11 craniopharyngiomas and five tuberculum sellae meningiomas, were enrolled in this study. The tumors were resected through an endoscope‐assisted supraorbital keyhole approach via a small skin incision within the eyebrow. Complete removal of the sellar region tumors was achieved in all 35 cases by endoscope‐assisted supraorbital keyhole approach. Mean length of hospital stay after surgery was 10.2 days (range 5 – 17). There was no patient with evidence of residual or recurrent tumor during the follow‐up period. There was no infection, bleeding, further vision impairment, oculomotor nerve injury or other cranial nerve injury symptom owing to surgery. Though some patients suffered from insipidus, hyperprolactinemia, subcutaneous edema or other postoperative complications, they eventually recovered with or without drug administration. The supraorbital “keyhole” approach with endoscopic assistance in the surgical treatment of benign tumors around the sellar region is an ideal pattern.

Contralateral haematoma secondary to decompressive craniectomy performed for severe head trauma: A descriptive study of 15 cases

Background: Contralateral haematoma is an infrequent but severe complication of decompressive craniectomy for head trauma. Method: A retrospective study was performed of patients developing this complication after decompressive craniectomy for head trauma in the institute. Demographics, mechanism of trauma, time interval between trauma and first operation, time interval between first operation and onset of contralateral haematoma and patients’ outcomes were recorded for further analysis. Results: Fifteen patients developed this complication in the study; most had epidural haematomas, which appeared within the first 12 hours after decompressive craniectomy in 13 patients, including three haematomas that developed during surgical decompression. Contralateral cranial fracture is a major risk factor for this condition. Only one patient recovered to mild disability. All remaining patients had poor outcomes, with Glasgow coma scale scores ≤3, except for one patient who was lost to follow-up. A literature review of similar studies including 36 patients revealed similar characteristics. Conclusion: Contralateral haematoma secondary to surgical decompression in head trauma can lead to a poor outcome. The prompt detection and removal of the haematoma are keys to management and routine recurrent computed tomography is recommended after the first operation.

Serial Attacks: Contralateral Hematoma Secondary to Decompressive Craniectomy for Traumatic Brain Injury Led to Posttraumatic Cerebral Infarction.

A 40-year-old man suffered severe brain injury and received left side subdural hematoma evacuation with decompressive craniectomy. Intraoperative brain swelling had occurred during the surgery. Postoperative computed tomography (CT) scan was done immediately and showed a contralateral epidural hematoma resulting in herniation. Secondary hematoma evacuation was performed and found a linear fracture near a bleeding meningeal artery. 2 days later CT scan showed cerebral infarction mainly in right posterior cerebral artery distribution. Early diagnosis by postoperative CT scan or other potential ways such as intraoperative sonography is important to prompt treatments and interrupt the pathophysiological chain of the serial attacks.

Early decompressing craniectomy in patients with traumatic brain injury and cerebral edema

Abstract Background: Decompressing craniectomy (DC) is an important method for the management of severe traumatic brain injury (TBI). Objective: To analyze the effect of prophylactic DC within 24 hours after head trauma TBI. Methods: Seventy-two patients undergoing prophylactic DC for severe TBI were included in this retrospective study. Both of the early and late outcomes were studied and the prognostic factors were analyzed. Results: In this series, cumulative death in the first 30 days after DC was 26%, and 28 (53%) of 53 survivors in the first month had a good outcomes. The factors including Glasgow Coma Score (GCS) score at admission, whether the patient had an abnormal pupil response and whether the midline shift was greater than 5 mm were most important prognostic factors for the prediction of death in the first 30 days and the final outcome at 6 months after DC. Conclusion: Prophylactic DC plays an important role in the management of highly elevated ICP, especially when other methods of reduction of ICP are unavailable.

Neuroprotection of hyperbaric oxygen treatment for traumatic brain injury involving autophagy pathway in rats

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