Wu-Fu Chen

Acute autologous bone flap infection after cranioplasty for postinjury decompressive craniectomy

BACKGROUNDnAcute bone flap infection is a devastating complication after cranioplasty for postinjury decompressive craniectomy. We aim to identify the risk factors of autologous bone flap infection.nnnMETHODSnWe enrolled 151 patients undergoing 153 cranioplasties in the 4-year retrospective study. Autologous bones stored at -75°C were used in the cranioplasties. Acute bone flap infection was defined as the onset of infection ≤14 days after cranioplasty. The epidemiological data of patients and details of the cranioplasty procedure were recorded.nnnRESULTSnAcute bone flap infection was identified in five of the 153 cranioplasties, accounting for 3.3% of all episodes. Three of the 5 infected patients and five of 143 uninfected patients presented with dysfunction of subgaleal drainage comparatively, which was significantly different (p=0.001). Statistical analysis of the cranioplasty procedures and subsequent results of the two patient groups revealed the following significant findings: the duration of operation (p=0.03) and the length of hospital stay after cranioplasty (p<0.001).nnnCONCLUSIONSnDysfunction of subgaleal drainage and long operative duration of cranioplasty are risk factors of acute autologous bone flap infection. Regarding the prolonged hospital stay in complicated patients, better surgical techniques should be implemented in order to eliminate the risks of infection.

Computer-assisted pedicle screw placement for thoracolumbar spine fracture with separate spinal reference clamp placement and registration

BACKGROUNDnThe objective of the study was to improve the accuracy of computer-assisted pedicle screw installation in the spine. This study evaluates the accuracy of computer-assisted pedicle screw placement with separate spinal reference clamp placement and registration on each instrumented vertebra for thoracolumbar spine fractures.nnnMETHODSnPostoperative radiographs and CT scans assessed the accuracy of pedicle screw placement in 21 adult patients on each instrumented vertebra. Screw placements were graded as good if the screws were placed in the central core of the pedicle and the cancellous portion of the body. Screw placements were graded as fair if the screws were placed slightly eccentrically, causing erosion of the pedicular cortex, and with less than a 2-mm perforation of the pedicular cortex. Screw placements were graded as poor if screws were placed eccentrically with a large portion of the screw extending outside the cortical margin of the pedicle and with more than a 2-mm perforation of the pedicular cortex.nnnRESULTSnA total of 140 image-guided pedicle screws were placed in 21 patients: 78 in the thoracic and 62 in the lumbar spine. Of the 140 pedicle screw placements, 96.4% (135/140) were categorized as good; 3.6% (5/140), fair; and 0% were poor. All 5 fair placement screws were placed in the thoracic spine without any mobility.nnnCONCLUSIONnSeparate registration increases accuracy of screw placement in thoracolumbar pedicle instrumentation. Separate spinal reference clamp placement in the instrumented vertebra provides real-time virtual imaging that decreases the possibility of downward displacement during manual installation of the screw.

Contralateral subdural effusion after decompressive craniectomy in patients with severe traumatic brain injury: clinical features and outcome.

BACKGROUNDnContralateral subdural effusion (SDE) is usually considered as an uncommon complication after decompressive craniectomy (DC) for head trauma. This complication may need more aggressive treatment because of its tendency to cause midline shift and neurologic deterioration. In this article, we present our experience with this group of patients and discuss the diagnosis and management of this entity.nnnMETHODSnThis study included 13 patients with severe traumatic brain injury who developed contralateral SDE after DC. Clinical and radiographic information was obtained through a retrospective review of the medical records and the radiographs.nnnRESULTSnThe average time from the procedure of DC to the diagnosis of contralateral SDE was 13 days. Deterioration of clinical condition or appearance of new symptoms/signs related to the contralateral SDE was noted in four patients. In the remaining nine patients without apparent clinical deterioration, the contralateral SDE was discovered on routine computed tomography scan. Six patients were treated conservatively and the contralateral SDE resolved gradually. In six patients who underwent burr hole craniectomy to evacuate the SDE, the operation had successfully drained the SDE in four patients. Two patients received subsequent subduroperitoneal shunt to manage the reaccumulation of SDE. In one patient, subduroperitoneal shunt and cranioplasty were performed simultaneously to treat the SDE. Subsequently, six patients (46.2%) developed hydrocephalus and underwent ventriculoperitoneal shunt operation.nnnCONCLUSIONSnContralateral SDE may not be a rare complication after DC. Its diagnosis may be delayed or missed when it is asymptomatic or the clinical condition of the patient masks its clinical manifestations. It may be reasonable to repeat a computed tomography scan to detect contralateral SDE 2 weeks to 3 weeks after DC, irrespective of the clinical condition. In addition, posttraumatic hydrocephalus is a common late consequence in these patients. Close surveillance in these patients is indicated to prompt appropriate management.

Characterization of acute post-craniectomy seizures in traumatically brain-injured patients

PURPOSEnDecompressive craniectomy (DC) is a life-saving measure for traumatic brain injury (TBI), but acute seizures following this procedure may have a devastating effect. We aim to investigate the clinical characteristics of acute post-craniectomy seizures.nnnMETHODSnFor this retrospective study, we enrolled 195 patients undergoing DC for TBI. Acute post-craniectomy seizure was defined as seizures occurring within 7 days of DC.nnnRESULTSnThe incidence of acute seizure was 10.8% (21/195). 19 of 21 seizures occurred within 3 days following DC. None progressed to status epilepticus, but 16 of 21 patients (76.2%) with acute seizure developed epilepsy. There was no independent risk factor in the multivariate regression model. The mean hospital stay was 44.8 ± 34.6 and 28.8 ± 32.3 days for patients with and without acute seizures, respectively (p=0.035). The neurological outcome at discharge showed no inter-group difference (p=0.917). The in-hospital mortality rate was 28.6% for patients with seizures and 31.0% for patients without seizures (p=0.817).nnnCONCLUSIONnAcute seizures occur mostly within the first 3 days following DC. Neurological outcome and mortality rate at discharge does not differ between patients with or without seizures, but the duration of hospital stay is significantly longer for acute seizure patients.

Volume of chronic subdural haematoma: Is it one of the radiographic factors related to recurrence?

BACKGROUNDnRecurrence of chronic subdural haematoma (CSDH) is a significant issue in neurosurgical practice, and to distinguish individuals at high risk is important. In this study, we aim to clarify the relationship between quantitative haematoma volume and recurrence of CSDH.nnnMETHODSnFor this two-year retrospective study, 94 patients with CSDH were enrolled and all underwent burr-hole craniostomy with closed-system drainage. The volume of haematoma before surgery was quantitatively analysed by computed tomography (CT) of the brain. The patients were subdivided into 2 groups based on whether recurrence of CSDH was present or not. We investigated the intergroup differences in the volume of haematoma and other radiographic parameters.nnnRESULTSnRecurrence of CSDH was identified in 13 of 94 patients (14%). Univariable analysis of CT features revealed significant differences in the volume of haematoma, bilateral cerebral convexity, and layering of the haematoma. To adjust for the confounding effect, these 3 parameters were entered into multivariable logistic regression analysis. Ultimately, neither the volume of haematoma (p=0.449) or bilateral cerebral convexity (p=0.123) was relevant in this model. Only the presence of layering of the haematoma was independently associated with recurrence of CSDH (p=0.009).nnnCONCLUSIONnThe volume of CSDH is not related to recurrence in patients undergoing burr-hole craniostomy with closed-system drainage. Layering of the haematoma was the only independent risk factor on CT images for recurrence of CSDH in our series.

Safety of the nonabsorbable dural substitute in decompressive craniectomy for severe traumatic brain injury.

BACKGROUNDnArtificial dural substitutes are increasingly being used in decompressive craniectomy to prevent peridural fibrosis and facilitate cranioplasty for patients with head injury. The safety of the dural substitute should be systemically evaluated. We focus on Neuro-Patch (B. Braun, Boulogne, France), a nonabsorbable substitute and commonly used by neurosurgeons.nnnMETHODSnIn this retrospective study, 132 patients undergoing 135 craniectomies and cranioplasties for traumatic brain injury were enrolled. We subdivided the operations into two groups on the basis of whether Neuro-Patch was used (N = 50) or not (N = 85). Risk factors of neurosurgical site infection were assessed first. Then, we compared the occurrence of infective, hemorrhagic, and hydrodynamic morbidities after craniectomy and cranioplasty between the two groups.nnnRESULTSnThe incidence of neurosurgical site infection after craniectomy or cranioplasty showed no intergroup difference (p = 1.000). Postoperatively, extra-axial hematoma, which consists of subdural or epidural hematoma, occurred in 9 of 50 craniectomies (18.00%) with Neuro-Patch and 3 of 85 craniectomies (3.53%) without Neuro-patch, which was significantly different (p = 0.009). The rates of hydrodynamic morbidities (subdural hygroma or cerebrospinal fluid leakage) after the procedures were similar between the two groups.nnnCONCLUSIONSnThe use of Neuro-Patch does not increase the incidence of neurosurgical site infection and hydrodynamic complications, including subdural hygroma and cerebrospinal fluid leakage, after decompressive craniectomy or cranioplasty for severe traumatic brain injury. However, extra-axial hematoma at the site of craniectomy is more often encountered in patients with Neuro-Patch and forms a compressive lesion on the adjacent brain.

The Prognosis of Acute Blunt Cervical Spinal Cord Injury

BACKGROUNDnCervical spinal cord injury (SCI) is a devastating event for the patient and family. It has a huge impact on society because of the intensive resources required to manage the patient in both the acute and rehabilitation phases. There is a need for better delineation of potential prognostic factors and outcomes in patients with acute cervical SCI.nnnMETHODSnIn this 5-year retrospective study, 75 adult patients diagnosed with acute nonfracture and nondislocation cervical SCI were enrolled into this study. Cervical X-ray and magnetic resonance imaging were available for all patients at admission and discharge. Epidemiologic data, management, complications, neurologic status, and change were assessed. Neurologic recovery from acute cervical SCI was determined by changes in the Japanese Orthopaedic Association score.nnnRESULTSnThirty-eight patients had surgical intervention, accounting for 50.67% (38 of 75) of the episodes. The Japanese Orthopaedic Association outcome score between the two groups, with or without surgical intervention, was statistically significant (p = 0.035). Statistical analysis of the clinical manifestations and neurologic images of the two patient groups revealed the following significant findings: limb weakness (p = 0.025) and days of hospitalization (p = 0.039).nnnCONCLUSIONSnThe treatment of acute nonfracture and nondislocation cervical SCI is still controversial and presents therapeutic challenges. A careful neurologic examination and high-resolution magnetic resonance imaging evaluation are necessary to determine whether surgical intervention is indicated. According to our data, when patients present with acute limb weakness, surgical intervention is necessary to improve the outcome.

The value of serial plasma nuclear and mitochondrial DNA levels in acute spontaneous intra-cerebral haemorrhage

Increased plasma nuclear and mitochondrial DNA levels may be connected to disease severity following spontaneous intra‐cerebral haemorrhage (ICH). This study tested the hypothesis that plasma nuclear and mitochondrial DNA levels are substantially increased in acute ICH and can predict treatment outcomes.

Risk factors for acute symptomatic cerebral infarctions after spontaneous supratentorial intra-cerebral hemorrhage

Cerebral infarctions are unfavorable outcomes of spontaneous intra-cerebral hemorrhage (ICH). To date, there have been no reports on risk factors that are predictive of acute symptomatic cerebral infarctions. With the aim of determining the potential risk factors that are predictive of acute symptomatic cerebral infarctions in patients with spontaneous supratentorial ICH, we have retrospectively evaluated 212 hospitalized patients with spontaneous ICH and compared those who developed a complicated cerebral infarction with those who did not. Cerebral infarctions developed in 8.02% (17/212) of the patient cohort. Neuro-imaging findings between the two patient groups revealed that the presence of intra-ventricular hemorrhage (IVH), hydrocephalus, and the median value of intra-cranial hematoma on admission were significant factors, as well as neurosurgical intervention. However, the multiple logistic regression analysis revealed that only the presence of IVH had an odds ratio of 4.7 (95% confidence intervalxa00.06–0.75; pxa0=xa00.016) in patients with acute symptomatic infarctions. The results indicate that the presence of IVH may imply a danger of cerebrovascular complications when treating spontaneous supratentorial ICH during hospitalization. The frequency of acute symptomatic cerebral infarctions in patients with spontaneous supratentorial ICH is high (8%) and is associated with longer hospitalization and worse outcome.

Risk factors for delayed neuro-surgical intervention in patients with acute mild traumatic brain injury and intracranial hemorrhage

BackgroundMild traumatic brain injury (TBI) patients with initial traumatic intracranial hemorrhage (tICH) and without immediate neuro-surgical intervention require close monitoring of their neurologic status. Progressive hemorrhage and neurologic deterioration may need delayed neuro-surgical intervention. This study aimed to determine the potential risk factors of delayed neuro-surgical intervention in mild TBI patients with tICH on admission.MethodsThree hundred and forty patients with mild TBI and tICH who did not need immediate neuro-surgical intervention on admission were evaluated retrospectively. Their demographic information, clinical evaluation, laboratory data, and brain CT was reviewed. Delayed neuro-surgical intervention was defined as failure of non-operative management after initial evaluation. Risk factors of delayed neuro-surgical intervention on admission were analyzed.ResultsDelayed neuro-surgical intervention in mild TBI with tICH on initial brain CT accounted for 3.8xa0% (13/340) of all episodes. Higher WBC concentration, higher initial ISS, epidural hemorrhage (EDH), higher volume of EDH, midline shift, and skull fracture were risk factors of delayed neuro-surgical intervention. The volume of EDH and skull fracture is independent risk factors. One cubic centimeter (cm3) increase in EDH on initial brain CT increased the risk of delayed neurosurgical intervention by 16xa0% (pu2009=u20090.011; OR: 1.190, 95xa0% CI:1.041–1.362).ConclusionsMild TBI patients with larger volume of EDH have higher risk of delayed neuro-surgical interventions after neurosurgeon assessment. Longer and closer neurological function monitor and repeated brain image is required for those patients had initial larger EDH. A large-scale, multi-centric trial with a bigger study population should be performed to validate the findings.