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INTRODUCTION: Research quality within the neurosurgical field remains suboptimal. Therefore, many studies published in the neurosurgical literature lack enough statistical power to establish the presence or absence of clinically important differences between treatment arms. The field of neurotrauma deals with additional challenges, with fewer financial incentives and restricted resources in low-income and middle-income countries with the highest burden of neurotrauma diseases. In this systematic review, we aim to estimate the prevalence of false claims of equivalence in the neurosurgical trauma literature and identify its predictive factors. METHODS AND ANALYSIS: The Preferred Reporting Items for Systematic Review and Meta-Analyses recommendations were followed. Randomised clinical trials that enrolled only traumatic brain injury patients and investigated any type of intervention (surgical or non-surgical) will be eligible for inclusion. The MEDLINE/PubMed database will be searched for articles in English published from January 1960 to July 2020 in 15 top-ranked journals. A false claim of equivalence will be identified by insufficient power to detect a clinically meaningful effect: for categorical outcomes, a difference of at least 25% and 50%, and for continuous outcomes, a Cohen's d of at least 0.5 and 0.8. Using the number of patients in each treatment arm and the minimum effect sizes to be detected, the power of each study will be calculated with the assumption of a two-tailed alpha that equals 0.05. Standardised differences between the groups with and without a false claim of equivalence will be calculated, and the variables with a standardised difference equal or above 0.2 and 0.5 will be considered weakly and strongly associated with false claims of equivalence, respectively. The data analysis will be blinded to the authors and institutions of the studies. ETHICS AND DISSEMINATION: This study will not involve primary data collection. Therefore, formal ethical approval will not be required. The final systematic review will be published in a peer-reviewed journal and presented at appropriate conferences.
Assuntos
Lesões Encefálicas Traumáticas , Revisões Sistemáticas como Assunto , Humanos , Lesões Encefálicas Traumáticas/cirurgia , Lesões Encefálicas Traumáticas/epidemiologia , Procedimentos Neurocirúrgicos , Projetos de Pesquisa , Ensaios Clínicos Controlados Aleatórios como Assunto , PrevalênciaRESUMO
Perfusion Computed Tomography (PCT) is an alternative tool to assess cerebral hemodynamics during trauma. As acute traumatic subdural hematomas (ASH) is a severe primary injury associated with poor outcomes, the aim of this study was to evaluate the cerebral hemodynamics in this context. Five adult patients with moderate and severe traumatic brain injury (TBI) and ASH were included. All individuals were indicated for surgical evacuation. Before and after surgery, PCT was performed and cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were evaluated. These parameters were associated with the outcome at 6 months post-trauma with the extended Glasgow Outcome Scale (GOSE). Mean age of population was 46 years (SD: 8.1). Mean post-resuscitation Glasgow coma scale (GCS) was 10 (SD: 3.4). Mean preoperative midline brain shift was 10.1 mm (SD: 1.8). Preoperative CBF and MTT were 23.9 ml/100 g/min (SD: 6.1) and 7.3 s (1.3) respectively. After surgery, CBF increase to 30.7 ml/100 g/min (SD: 5.1), and MTT decrease to 5.8s (SD:1.0), however, both changes don't achieve statistically significance (p = 0.06). Additionally, CBV increase after surgery, from 2.34 (SD: 0.67) to 2.63 ml/100 g (SD: 1.10), (p = 0.31). Spearman correlation test of postoperative and preoperative CBF ratio with outcome at 6 months was 0.94 (p = 0.054). One patient died with the highest preoperative MTT (9.97 s) and CBV (4.51 ml/100 g). CBF seems to increase after surgery, especially when evaluated together with the MTT values. It is suggested that the improvement in postoperative brain hemodynamics correlates to favorable outcome.
Assuntos
Lesões Encefálicas Traumáticas , Circulação Cerebrovascular , Escala de Coma de Glasgow , Hematoma Subdural Agudo , Tomografia Computadorizada por Raios X , Humanos , Pessoa de Meia-Idade , Masculino , Feminino , Adulto , Hematoma Subdural Agudo/diagnóstico por imagem , Hematoma Subdural Agudo/cirurgia , Tomografia Computadorizada por Raios X/métodos , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Lesões Encefálicas Traumáticas/cirurgia , Seguimentos , Hemodinâmica , Escala de Resultado de Glasgow , Encéfalo/diagnóstico por imagem , Encéfalo/irrigação sanguínea , Resultado do Tratamento , Volume Sanguíneo Cerebral , Imagem de Perfusão/métodos , PerfusãoRESUMO
OBJECTIVE: There is no consensus on the use of decompressive craniectomy (DC) to manage severe traumatic brain injury (sTBI). We evaluated the profile of pediatric patients admitted with sTBI and assessed functional outcomes, 6 months posttrauma, in patients who had a DC and in those who had not, and the functional outcomes of early versus late DCs. PATIENTS AND METHODS: This case-control observational study evaluated pediatric patients admitted for sTBI in Puerto Rico (June 2016-October 2018); we included patients admitted within 24 hours of injury and had a Glasgow Coma Scale (GCS) of 8 or lower. 6-month post trauma outcomes were measured with the Glasgow Outcome Scale Extended Pediatric (GOS-E Peds). RESULTS: 20 patients were included; 15 underwent a DC and 5 comprised the control group. We found no differences in terms of sex, age, GCS score, Pediatric Risk of Mortality score, or Pediatric Trauma Score. However, in the DC group, a higher percentage of patients presented significant cerebral herniation in the initial computed tomography scan (CT) (DC: 73%; control: 0%; P = .005). No differences were found regarding intracranial pressure (ICP), cerebral perfusion pressure, mean arterial pressure, PaCO2, or temperature. Patients in the DC group had longer hospital stay (DC: 41; control: 17 days; P = .0005). All patients with DC survived, with an early procedure being associated with favorable outcomes. CONCLUSION: As determined 6 months post-trauma, this study showed that early DC increased survival and improved functionality.
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Lesões Encefálicas Traumáticas , Craniectomia Descompressiva , Humanos , Criança , Craniectomia Descompressiva/efeitos adversos , Craniectomia Descompressiva/métodos , Lesões Encefálicas Traumáticas/cirurgia , Tomografia Computadorizada por Raios X/métodos , Escala de Coma de Glasgow , Tempo de Internação , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Decompressive craniectomy is part of the acute management of several neurosurgical illnesses, and is commonly followed by cranioplasty. Data are still scarce on the functional and cognitive outcomes following cranioplasty. We aim to evaluate these outcomes in patients who underwent cranioplasty following traumatic brain injury (TBI) or stroke. METHODS: In this prospective cohort, we assessed 1-month and 6-month neuropsychological and functional outcomes in TBI and stroke patients who underwent cranioplasty at a Brazilian tertiary center. The primary outcome was the change in the Digits Test at 1 and 6 months after cranioplasty. Repeated measures general linear models were employed to assess the patients' evolution and interactions with baseline characteristics. Effect size was estimated by the partial η2. RESULTS: A total of 20 TBI and 14 stroke patients were included (mean age 42 ± 14 years; 52.9% male; average schooling 9.5 ± 3.8 years; 91.2% right-handed). We found significant improvements in the Digits Tests up to 6 months after cranioplasty (p = 0.004, partial η2 = 0.183), as well as in attention, episodic memory, verbal fluency, working memory, inhibitory control, visuoconstructive and visuospatial abilities (partial η2 0.106-0.305). We found no interaction between the cranioplasty effect and age, sex or schooling. Patients submitted to cranioplasty earlier (<1 year) after injury had better outcomes. CONCLUSION: Cognitive and functional outcomes improved after cranioplasty following decompressive craniectomy for stroke or TBI. This effect was consistent regardless of age, sex, or education level and persisted after 6 months. Some degree of spontaneous improvement might have contributed to the results.
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Lesões Encefálicas Traumáticas , Craniectomia Descompressiva , Acidente Vascular Cerebral , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Lactente , Feminino , Estudos de Coortes , Estudos Prospectivos , Resultado do Tratamento , Craniectomia Descompressiva/efeitos adversos , Lesões Encefálicas Traumáticas/cirurgia , Acidente Vascular Cerebral/cirurgiaRESUMO
BACKGROUND: Cranioplasty is the used method in neurosurgery for repairing cranial bone defects. In our environment, the most widely used material is cryopreserved autologous bone (ABCp). OBJECTIVE: A retrospective observational study was proposed in order to analyze complications in patients who underwent decompressive craniectomy for brain trauma, with subsequent cranioplasty with ABCp. METHOD: Patients who underwent cranioplasties with consecutive ABCp performed at our institution over a four-year period (2016-2019) with subsequent follow-up were included, collecting multiple variables in relation to the appearance of complications. RESULTS: 113 cranioplasties were performed, of which 85.8% (n = 97) were performed with ABCp. Mainly with frontotemporoparietal bone defect (94.84%) performed late (> 3 months) in 91.76%. The complication rate was 16.49%, the most significant being the infection of the surgical site (n = 8, 8.24%), the presence of intracranial hematoma (n = 3, 3.09%) and the reabsorption of the autologous bone (n = 2, 2.06%), meriting surgical management in nine of them (9.27%). CONCLUSIONS: ABCp is a valid and safe option, which meets the basic characteristics to consider it the ideal material, with an acceptable rate of complications, biocompatible, with osteogenic potential, adequate protection of the brain and decrease in surgery costs.
ANTECEDENTES: La craneoplastia es el método utilizado en neurocirugía para reparar los defectos óseos craneanos. En nuestro medio, el material utilizado mayormente es el hueso autólogo criopreservado (HACp). OBJETIVO: Realizamos un estudio retrospectivo observacional para analizar las complicaciones en pacientes sometidos a craniectomía descompresiva por trauma craneoencefálico y realización de craneoplastia con HACp. MÉTODO: Se incluyeron pacientes que fueron sometidos a craneoplastias con HACp consecutivas realizadas en un periodo de 4 años (2016-2019) con seguimiento posterior, recabando múltiples variables en relación con la aparición de complicaciones. RESULTADOS: Se realizaron 113 craneoplastias, de las cuales el 85.8% (n = 97) fueron realizadas con HACp, principalmente con defecto óseo frontotemporoparietal (94.84%), realizadas de forma tardía (> 3 meses) en el 91.76%. El índice de complicaciones fue del 16.49%, siendo las más significativas la infección del sitio quirúrgico (n = 8, 8.24%), la presencia de hematoma endocraneano (n = 3, 3.09%) y la reabsorción del hueso autólogo (n = 2, 2.06%), ameritando manejo quirúrgico en nueve ocasiones (9.27%). CONCLUSIONES: El HACp es una opción válida y segura, la cual cumple con las características para considerarlo el material ideal, con un aceptable índice de complicaciones, biocompatible, con potencial osteogénico, adecuada protección encefálica y disminución de los costos de la cirugía.
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Lesões Encefálicas Traumáticas , Craniectomia Descompressiva , Procedimentos de Cirurgia Plástica , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/cirurgia , Craniectomia Descompressiva/efeitos adversos , Craniectomia Descompressiva/métodos , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Estudos Retrospectivos , Crânio/cirurgiaRESUMO
OBJECTIVE: This study aimed to develop and validate a practical nomogram to predict the occurrence of post-traumatic hydrocephalus in patients who have undergone decompressive craniectomy for traumatic brain injury. METHODS: A total of 516 cases were enrolled and divided into the training (n=364) and validation (n=152) cohorts. Optimal predictors were selected through least absolute shrinkage and selection operator regression analysis of the training cohort then used to develop a nomogram. Receiver operating characteristic, calibration plot, and decision curve analysis, respectively, were used to evaluate the discrimination, fitting performance, and clinical utility of the resulting nomogram in the validation cohort. RESULTS: Preoperative subarachnoid hemorrhage Fisher grade, type of decompressive craniectomy, transcalvarial herniation volume, subdural hygroma, and functional outcome were all identified as predictors and included in the predicting model. The nomogram exhibited good discrimination in the validation cohort and had an area under the receiver operating characteristic curve of 0.80 (95%CI 0.72-0.88). The calibration plot demonstrated goodness-of-fit between the nomogram's prediction and actual observation in the validation cohort. Finally, decision curve analysis indicated significant clinical adaptability. CONCLUSION: The present study developed and validated a model to predict post-traumatic hydrocephalus. The nomogram that had good discrimination, calibration, and clinical practicality can be useful for screening patients at a high risk of post-traumatic hydrocephalus. The nomogram can also be used in clinical practice to develop better therapeutic strategies.
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Lesões Encefálicas Traumáticas , Craniectomia Descompressiva , Hidrocefalia , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/cirurgia , Estudos de Coortes , Craniectomia Descompressiva/efeitos adversos , Humanos , Hidrocefalia/epidemiologia , Hidrocefalia/etiologia , Hidrocefalia/cirurgia , NomogramasRESUMO
SUMMARY OBJECTIVE: This study aimed to develop and validate a practical nomogram to predict the occurrence of post-traumatic hydrocephalus in patients who have undergone decompressive craniectomy for traumatic brain injury. METHODS: A total of 516 cases were enrolled and divided into the training (n=364) and validation (n=152) cohorts. Optimal predictors were selected through least absolute shrinkage and selection operator regression analysis of the training cohort then used to develop a nomogram. Receiver operating characteristic, calibration plot, and decision curve analysis, respectively, were used to evaluate the discrimination, fitting performance, and clinical utility of the resulting nomogram in the validation cohort. RESULTS: Preoperative subarachnoid hemorrhage Fisher grade, type of decompressive craniectomy, transcalvarial herniation volume, subdural hygroma, and functional outcome were all identified as predictors and included in the predicting model. The nomogram exhibited good discrimination in the validation cohort and had an area under the receiver operating characteristic curve of 0.80 (95%CI 0.72-0.88). The calibration plot demonstrated goodness-of-fit between the nomogram's prediction and actual observation in the validation cohort. Finally, decision curve analysis indicated significant clinical adaptability. CONCLUSION: The present study developed and validated a model to predict post-traumatic hydrocephalus. The nomogram that had good discrimination, calibration, and clinical practicality can be useful for screening patients at a high risk of post-traumatic hydrocephalus. The nomogram can also be used in clinical practice to develop better therapeutic strategies.
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Humanos , Craniectomia Descompressiva/efeitos adversos , Lesões Encefálicas Traumáticas/cirurgia , Lesões Encefálicas Traumáticas/complicações , Hidrocefalia/cirurgia , Hidrocefalia/etiologia , Hidrocefalia/epidemiologia , Estudos de Coortes , NomogramasRESUMO
Introduction Low-velocity penetrating brain injury is not prevalent. In some conditions such as childhood, and with the penetration of a pellet in weak spots of skull, low-velocity penetrating brain injury is expected; however, high-velocity projectiles have also been reported as the cause of severe brain injuries. One of the complications of penetrating brain injury is infection, in which different types ofmicroorganisms play a role. The Streptococcus genus is the leading cause of abscess formation in nontraumatic patients. Multiple brain abscesses are not common. Case Presentation A 10-year-old boy with penetrating brain injury caused by an air gun pellet, who developed signs and symptoms of high intracranial pressure 18 days after the trauma. After the imaging scans and the detection of multiple brain abscesses and severe brain edema, prompt surgical intervention was performed for all three lesions in a single operation. The culture of a pus specimen was positive for Streptococcus species, and, with adequate antibiotic therapy, the patient was discharged from the hospital in good condition. Conclusion Brain injurywith air gun shot is not prevalent. The penetration of a low-velocity air gun pellet in weak points of the skull (such as the orbit, the squamous portion of the temporal bone, and the cranial suture), specially in children, can cause significant brain injuries.
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Humanos , Masculino , Criança , Infecções Estreptocócicas/tratamento farmacológico , Ferimentos por Arma de Fogo/cirurgia , Abscesso Encefálico/cirurgia , Lesões Encefálicas Traumáticas/cirurgia , Lesões Encefálicas Traumáticas/etiologia , Fraturas Cranianas/cirurgia , Fraturas Cranianas/etiologia , Fraturas Cranianas/diagnóstico por imagem , Streptococcus/patogenicidade , Abscesso Encefálico/etiologia , Abscesso Encefálico/diagnóstico por imagemRESUMO
Crossbow injuries to the head have seldom been reported in the literature, and they represent a unique type of penetrating brain injury (PBI) in which a low-velocity arrow results in an intracranial fragment larger than most high-velocity projectiles, usually with a lethal outcome.We present the case of a 34-year-oldman who attempted suicide with a self-inflicted cranial injury from a crossbow arrow, with a right parietal point of entry and a palpable subcutaneous tip in the left parietal region. The emergency team reported a Glasgow coma scale (GCS) score of 15, and the patient was brought sedated and intubated. Computed tomography (CT) imaging scans showed that the arrow crossed both parietal lobes, with mild subarachnoid hemorrhage and small cerebral contusions adjacent to its intracranial path. Careful retrograde removal of the penetrating arrow was performed in the CT suite, followed by an immediate CT scan, which excluded procedure-related complications. The patient woke up easily and was discharged 3 days later withmild left hand apraxia and no other neurologic deficits. To the best of our knowledge, there are no similar case reports describing both good clinical outcome and rapid discharge after a bihemispheric PBI. Individualizing the management of each patient is therefore crucial to achieve the best possible outcome as PBI cases still represent a major challenge to practicing neurosurgeons worldwide.
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Humanos , Masculino , Adulto , Lobo Parietal/cirurgia , Lobo Parietal/lesões , Ferimentos Perfurantes/cirurgia , Lesões Encefálicas Traumáticas/cirurgia , Hemorragia Subaracnóidea/complicações , Escala de Gravidade do Ferimento , Resultado do Tratamento , Lesões Encefálicas Traumáticas/diagnóstico por imagemRESUMO
After decompressive craniectomy (DC), cranioplasty (CP) can help to normalize vascular and cerebrospinal fluid circulation besides improving the patient's neurological status. The aim of this study was to investigate the effects of CP on cerebral hemodynamics and on cognitive and functional outcomes in patients with and without a traumatic brain injury (TBI). Over a period of 3 years, 51 patients were included in the study: 37 TBI patients and 14 non-TBI patients. The TBI group was younger (28.86 ± 9.71 versus 45.64 ± 9.55 years, P = 0.0001), with a greater proportion of men than the non-TBI group (31 versus 6, P = 0.011). Both groups had improved cognitive outcomes (as assessed by the Mini-Mental State Examination) and functional outcomes (as assessed by the Barthel Index and Modified Rankin Scale) 90 days after CP. In the TBI group, the mean velocity of blood flow in the middle cerebral artery ipsilateral to the cranial defect increased between the time point before CP and 90 days after CP (34.24 ± 11.02 versus 42.14 ± 10.19 cm/s, P = 0.0001). In conclusion, CP improved the neurological status in TBI and non-TBI patients, but an increment in cerebral blood flow velocity after CP occurred only in TBI patients.