Indicaciones de TAC de cráneo simple en pacientes menores de 2 años con trauma encefalocraneano leve / Indications for head computed tomography in patients younger than 2 years old with minor head injuries

Resumen Existe gran variabilidad en la práctica clínica en cuanto al uso de estudios imagenológicos, específicamente de la tomografía de cráneo simple en los casos de trauma encefalocraneano leve, más aun en pacientes menores de 2 años. En la mayoría de estos pacientes existe bajo riesgo de injuria intracraneal, sin embargo, este grupo etario plantea mayores retos diagnósticos por las dificultades en su evaluación y las pocas manifestaciones clínicas que podrían presentar dado a sus características anatómicas. Resulta necesario acogerse a las guías de práctica clínica que contengan reglas de decisión clínicas, que incluyan los signos y/o síntomas con mayor valor predictivo para detectar injuria intracraneal, costo efectivas y redundando en el beneficio del paciente.

Summary There is great variability in clinical practice with the use of imaging studies, specifically head computed tomography in cases of minor head injuries, even more so in patients younger than 2 years old. Most of these patients have low risk of intracranial injury; however, this age group represents greater challenges in the diagnosis, because of the difficulties in their assessment and lack of clinical results that could be present due to their anatomical characteristics. It is necessary to make clinical practice guidelines that include some key points like clinical signs and/or symptoms with greater predictive value for detecting intracranial injury, cost-effective interventions resulting in benefits for the patients.

Accuracy of the Free Hand Placement of an External Ventricular Drain (EVD) / 대한뇌혈관외과학회지

OBJECTIVE: Free hand insertion of an external ventricular drain (EVD) is one of the most common emergency neurosurgical procedures, usually performed on critically ill patients. Complications such as infection and hemorrhage that accompany the placement of an EVD have been studied thoroughly, but few reports have focused on the accuracy of EVD positioning. As a result, the authors of this paper retrospectively studied the accuracy of tip positioning in the placement of an EVD. METHODS: One hundred and thirteen emergency EVDs were performed through Kocher's point during the past 3 years. All patients underwent the following procedures: at least one routine post-EVD computed tomographic (CT) scan that was retrospectively reviewed for accuracy of the EVD tip position, calculation of the Evan's index, and measurement of the intracranial length of the EVD. We divided the EVD tip position into 6 groups as follows:1) ipsilateral frontal horn of the lateral ventricle, 2) contralateral frontal horn of the lateral ventricle, 3) third ventricle, 4) body of the ipsilateral or contralateral lateral ventricle, 5) basal cisterns, or 6) brain parenchyma. Among the 6 groups, only the ipsilateral frontal horn group was considered to be the correct position for the EVD tip. RESULTS: The mean age of the patients was 55.6+/-15.3 years (age range, 12~90 years), and the most common indication for the EVD was supratentorial intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) (57.5%). Forty-five out of a total of 113 EVDs were placed by inexperienced neurosurgical trainees, and the remaining 68 were placed by experienced practitioners. Among 113 post-EVD CT scans, 48 EVD tips (42.5%) were in the ipsilateral frontal horn of the lateral ventricle (considered to be the correct position); 22 (19.5%) were in the third ventricle, 16 (14.1%) in the body of the ipsilateral or contralateral lateral ventricle, 14 (12.4%) in the contralateral frontal horn of the lateral ventricle, 11 (9.7%) within the brain parenchyma and 2 (1.8%) in the basal cistern. The mean estimated EVD length was 57+/-8.4mm. The mean length of EVDs that were positioned in the ipsilateral frontal horn was 55+/-4.3 mm, whereas the mean lengths of EVDs in the parenchyma and basal cistern were 64+/-14mm and 72+/-3.5mm, respectively. In addition, there was no statistically significant relationship between the surgeon's experience and the accuracy of the position of the EVD tip (p > 0.05). CONCLUSION: Emergency free hand placement of an EVD might be an inaccurate procedure. Further multi-institutional prospective studies are required to assess the accuracy and complications of free hand insertion of EVDs in an emergency setting. Studies are also needed on the feasibility of routine use of intra-operative neuro-navigation of other guidance tools, such as ultrasonography.