Keigo Shigeta

Decompressive craniectomy with hematoma evacuation for large hemispheric hypertensive intracerebral hemorrhage.

Hemispheric hypertensive intracerebral hemorrhage (ICH) has a high mortality rate. Decompressive craniectomy (DC) has generally been used for the treatment of severe traumatic brain injury, aneurysmal subarachnoid hemorrhage, and hemispheric cerebral infarction. However, the effect of DC on hemispheric hypertensive ICH is not well understood. To investigate the effects of DC for treating hemispheric hypertensive ICH, we retrospectively reviewed the clinical and radiological findings of 21 patients who underwent DC for hemispheric hypertensive ICH. Eleven of the patients were male and 10 were female, with an age range of 22-75 years (mean, 56.6 years). Their preoperative Glasgow Coma Scale scores ranged from 3 to 13 (mean, 6.9). The hematoma volumes ranged from 33.4 to 98.1 mL (mean, 74.2 mL), and the hematoma locations were the basal ganglia in 10 patients and the subcortex in 11 patients. Intraventricular extensions were observed in 11 patients. With regard to the complications after DC, postoperative hydrocephalus developed in ten patients, and meningitis was observed in three patients. Six patients had favorable outcomes and 15 had poor outcomes. The mortality rate was 10 %. A statistical analysis showed that the GCS score at admission was significantly higher in the favorable outcome group than that in the poor outcome group (P = 0.029). Our results suggest that DC with hematoma evacuation might be a useful surgical procedure for selected patients with large hemispheric hypertensive ICH.

Prognostic factors in patients with primary brainstem hemorrhage.

OBJECTIVE Primary brainstem hemorrhage (PBH) frequently causes severe disturbances of consciousness, papillary abnormalities, as well as respiratory and motor disturbances. The prognosis has been reported to be highly dependent on the clinical severity at presentation and the presence of certain radiological markers. However, the number of PBH patients enrolled in previous reports tended to be small, and precise statistical analyses were also lacking. The aim of this study was to analyze the impact of clinical or radiologic parameters on the outcome of patients with PBH. METHODS We retrospectively reviewed 212 consecutive patients with PBH and analyzed the impact of the clinical or radiological parameters on the outcome of patients with PBH. RESULTS Of the 212 patients, 134 (63.2%) were male and 78 (36.8%) were female, with an age range of 17-97 years (mean, 60.3 years). The median admission GCS score was 4. The outcomes included a good recovery in 13 patients (6.1%), moderate disability in 27 (12.7%), severe disability in 27 (12.7%), a vegetative state in 23 (10.8%), and death in 122 (57.5%). A multivariate analysis demonstrated bilateral hematoma extension, a GCS score ≤8, the presence of hydrocephalus, gender, and the hematoma volume to all be significantly associated with the 3-month mortality, while the GCS score ≤8, the presence of a pupillary abnormality, and the hematoma volume were found to be associated with the 3-month poor outcome. CONCLUSION The identification of these factors is therefore considered to be useful for managing patients with PBH.

Postoperative computed tomography after surgery for head trauma.

BACKGROUND It is well known that intracranial lesions, which are already diagnosed on preoperative computed tomography, often expand after surgery, and the risk factors have been investigated. On the other hand, we have experienced cases in which new lesions, which were not detected on preoperative computed tomography, were found on postoperative computed tomography. However, little is known about the factors associated with such new postoperative lesions. Here, we investigated the predictive factors of new findings (NFs) on computed tomography early after surgery. METHODS We conducted a retrospective registry-based review of 186 consecutive patients who underwent surgery for traumatic brain injury and investigated the prognostic factors of NFs on computed tomography early after surgery. RESULTS Mean age was 51 years, and 67.2% were males among the 186 patients. NFs on postoperative computed tomography were observed in 29 patients (15.6%). A univariate analysis showed that Glasgow Coma Scale (GCS) score of 8 or less (p < 0.001), subdural hematoma as the primary indication for surgery (p = 0.012), midline shift (p < 0.001), absence of basal cistern (p < 0.001), and decompressive craniectomy and craniotomy as the surgical procedures (p < 0.001, p = 0.004, respectively) were significantly associated with NFs on postoperative computed tomography. A logistic regression analysis demonstrated that decompressive craniectomy as the surgical procedure (p = 0.001; odds ratio [OR], 8.1; 95% confidence interval [CI], 2.23–28.82), GCS score of 8 or less (p = 0.019; OR, 3.4; 95% CI, 1.23–9.52), and absence of basal cistern (p = 0.023; OR, 3.5; 95% CI, 1.19–10.35) were significant factors. CONCLUSION Early postoperative computed tomography after surgery for head trauma seems to be warranted in patients presenting with the indicated predictive factors of NFs. LEVEL OF EVIDENCE Prognostic/therapeutic study, level III.

Subacute Subdural Hematoma

Subacute subdural hematoma (SASDH) is a rare entity. We retrospectively reviewed 8 patients with SASDH. Four patients were male and 4 were female, with an age range of 45-87 years (mean, 67.8 years). The minimal level of deterioration ranged from 8 to 14 (mean, 10.5). The deterioration of neurological symptoms was confirmed 4-20 days after injury (mean, 12.9). The hematoma volume was increased in 6 patients. Seven patients underwent surgeries (burr-hole irrigation in 6, craniotomy in 1). The Glasgow Outcome Scale indicated a good recovery in 4 patients and moderate disability in 4 patients. Increased cerebral blood flow was observed just below the SDH in 1 patient. We consider that the hypoperfused tissue in the acute phase might become hyperperfused during the subacute phase owing to impaired autoregulation, and the hyperperfusion may be responsible for the development of the SASDH, leading to deterioration. Further investigations in a larger series are needed to elucidate the mechanism underlying the development of SASDH.

Hydrocephalus Following Decompressive Craniectomy for Ischemic Stroke

Numerous studies on hydrocephalus after decompressive craniectomy (DC) for severe traumatic brain injury have been reported, whereas there have been only two reports on DC for hemispheric cerebral infarction. Here, we present the clinical details of 23 patients who underwent DC for hemispheric cerebral infarction and the incidence of hydrocephalus following DC. Of the 23 patients, 13 were male and 10 were female, with an age range from 34 to 75 years (mean, 60.8 years). The areas of hemispheric infarctions were those of the middle cerebral arteries in 12 patients and of the internal carotid arteries in 11 patients. The mean preoperative GCS score was 6. Nineteen patients (82.6 %) underwent cranioplasty. Pre-cranioplasty hydrocephalus was observed in 11 (47.8 %) patients. Four patients who had precranioplasty hydrocephalus were transferred or died without cranioplasty, and post-cranioplasty hydrocephalus occurred in 7 (36.8 %). Only one patient underwent a shunt procedure after cranioplasty. We consider that the explanation for the discrepancies between our study and the previous studies might lie in the definition of hydrocephalus and the indications for shunting.

Traumatic Basal Ganglia Hematomas: An Analysis of 20 Cases

Twenty patients with traumatic basal ganglia hematoma (TBGH) were studied. Of the 20 patients, 16 were male and 4 were female, with an age range of 4-89 years (mean, 54.4 years). The causes of injury were traffic accidents in 12 patients and falls in 8. The mean admission GCS score was 7.5. Skull fractures were revealed in five patients (25 %). The hematoma was found in the putamen in 15 patients (80 %), the thalamus in 4, and the caudate in 1. The mean hematoma volume was 10.7 mL. The CT findings indicated focal contusions in 9 patients, subdural hematoma in 5, intraventricular hemorrhage in 4, subarachnoid hemorrhage in 10, and diffuse axonal injury in 5. Six patients (30 %) underwent surgery. The final outcomes were poor: 7 patients (35 %) died, 1 was in a vegetative state, 4 experienced severe disabilities, and 8 patients (40 %) made a favorable recovery. The statistical analysis identified the GCS score and midline shift as prognostic factors.Our study revealed interesting characteristics of TBGH, including a high frequency of putaminal involvement, a low frequency of skull fractures, a high frequency of associated intracranial lesions, and a high poor outcome and mortality rate.

Computed tomography after decompressive craniectomy for head injury.

New findings (NF) on postoperative CTs are -occasionally found in patients who undergo surgery for traumatic brain injury (TBI). We conducted a retrospective -registry-based review of the care of 102 patients who underwent decompressive craniectomy (DC) for TBI to investigate the prognostic factors of new findings on CT early after -surgery. Of the 102 patients, the mean age was 50 years and 69.6 % were male. The overall survival was 72.5 %. The primary indication for DC included subdural hematoma in 72 (70.6 %), epidural hematoma in 17 (16.7 %), and intraparenchymal contusion in 13 (12.7 %). New findings on postoperative CTs were observed in 26 patients (25.5 %). The univariate analysis showed that a GCS score ≤8 (P = 0.012) and the absence of a basal cistern (P = 0.012) were significantly associated with NF on postoperative CT. The logistic regression analysis demonstrated that the GCS score ≤8 (P = 0.041; OR, 3.0; 95 % CI, 1.048-8.517) was the only significant factor. TBI patients with a low GCS score who underwent DC should undergo additional CT evaluations immediately after surgery.

Outcome of traumatic brain injury in patients on antiplatelet agents: a retrospective 20-year observational study in a single neurosurgery unit

ABSTRACT Objective: To evaluate the outcomes after Traumatic Brain Injury (TBI) in patients taking Antiplatelet Agents (APAs). Methods: We reviewed the clinical records of 934 patients with TBI between 1995 and 2014. Multivariate analysis was performed to correlate patient outcome with various factors, including pre-injury APA intake. Cause of death was compared among groups stratified according to APA dose. Results: Increasing doses of APAs were positively associated with mortality rates, however, differences were primarily due to non-traumatic causes. APA therapy before injury was independent of both overall and non-traumatic mortality. In multivariate analysis, mortality was significantly correlated with the Charlson Comorbidity Index (CCI), pupillary abnormalities, age, Glasgow Coma Scale (GCS), head Abbreviated Injury Scale (AIS) and additional AIS >2. Conversely, non-traumatic mortality was associated with age, GCS, additional AIS >2 and CCI, though only CCI was correlated with increasing APA dose. Furthermore, no significant difference was observed when comparing mortalities according to CCI score among APA groups. Thus, mortalities were associated with the severity of pre-existing conditions rather than APA dose. Conclusions: The outcome of patients with TBI, who were on APAs may be determined by the severity of pre-existing conditions. Aggressive TBI treatment should be implemented when tolerable, regardless of pre-existing APA treatment status.