Nomogram for predicting post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury

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.

Microsurgical Cisternostomy for Treating Critical Patients with Traumatic Brain Injury - An alternative Therapeutic Approach

Introduction Traumatic brain injury (TBI) is a major cause of mortality around the world. Few advances regarding surgical approaches have been made in the past few years to improve its outcomes. Microsurgical cisternostomy is a well-established technique used in vascular and skull base surgery and recently emerges as a suitable procedure with lesser costs and morbidity when compared with decompressive craniectomy in patients with diffuse TBI. This study aims to describe the technique, indications, and limitations of cisternostomy and to compare it with decompressive craniectomy (DC). Methods A prospective study is being conducted after obtaining approval of the local human ethics research committee. Once the inclusion and exclusion criteria are applied, the patients are submitted to microsurgical cisternostomy, pre and postoperative neurological status and brain computed tomography (CT) evaluation. A detailed review was also performed, which discusses diffuse TBI, DC, and cisternostomy for the treatment of TBI. Results Two patients were submitted to cisternostomy after TBI and the presence of acute subdural hematoma and hugemidline shift at admission computed tomography. The surgery was authorized by the family (the informed consent form was signed). Both patients evolved with a good recovery after the procedure, and had a satisfactory control brain CT. No further surgeries were required after the initial cisternostomy. Conclusions Cisternostomy is an adequate technique for the treatment of selected patients affected by diffuse TBI, and it is a proper alternative to DC with lesser costs and morbidity, since a single neurosurgical procedure is performed. A prospective study is being conducted for a better evaluation and these were the initial cases of this new protocol.

Intracranial pressure following decompressive hemicraniectomy for malignant cerebral infarction: clinical and treatment correlations / Monitorização da pressão intracraniana em pacientes tratados com hemicraniectomia descompressiva por acidente vascular cerebral maligno de artéria cerebral média: correlações clínicas e terapêuticas

ABSTRACT Decompressive craniectomy (DC) reduces mortality and improves outcome in patients with massive brain infarctions. The role of intracranial pressure (ICP) monitoring following DC for stroke has not been well established. Methods: We evaluated 14 patients admitted to a tertiary hospital with malignant middle cerebral artery infarctions, from October 2010 to February 2015, who underwent DC and had ICP monitoring. Patients with and without episodes of ICP elevation were compared. Results: Fourteen patients were submitted to DC and had ICP monitoring following the procedure during the period. Ten patients (71.4%) had at least one episode of sustained elevated ICP in the first seven days after surgery. Maximal ICP levels had no correlation with age, time to hemicraniectomy or Glasgow Coma Scores at admission, but had a trend toward correlation with the National Institutes of Health Stroke Scale score at admission (p = 0.1). Ventriculitis occurred in 21.4% of the patients. Conclusions: High ICP episodes and ventriculitis were common in patients following hemicraniectomy for malignant middle cerebral artery strokes. Therefore, the implications of ICP and benefits of the procedure should be firmly established.

RESUMO Craniectomia descompressiva (CD) reduz a mortalidade e melhora o desfecho em pacientes com infartos malignos de artéria cerebral média (ACM). O papel da monitorização da pressão intracraniana (PIC) após CD para infartos malignos de ACM não está bem estabelecido. Métodos: Avaliamos pacientes consecutivos internados em um hospital terciário com infartos malignos de ACM de outubro/2010 a fevereiro/2015 tratados com CD e submetidos à monitorização da PIC. Foram comparados pacientes com e sem episódios de elevação de PIC. Resultados: Quatorze pacientes (idade média 49,0 ± 12,4 anos, 42,9% do sexo masculino) foram avaliados. Dez pacientes (71,4%) tiveram pelo menos um episódio de elevação da PIC nos primeiros sete dias após a cirurgia. A PIC máxima média foi de 26,71 ± 11,64 mmHg. Os níveis máximos de PIC não apresentaram correlação com a idade, o tempo de hemicraniectomia ou com a pontuação na Escala de Coma de Glasgow na admissão, mas houve tendência a ser correlacionada com a pontuação da National Institutes of Health Stroke Scale na admissão (p = 0,1). Ventriculite ocorreu em 21,4% dos pacientes. Conclusões: Os episódios de aumento da PIC foram comuns em pacientes tratados com CD por infarto maligno de MCA e ventriculite foi evento adverso frequente nesses pacientes. Portanto, as implicações da monitorização da PIC sobre o resultado funcional, bem como os riscos e benefícios do procedimento, devem ser melhor estabelecidos.

Coma secundario a síndrome del trefinado / Coma due to syndrome of the trephined

El síndrome del trefinado o craniectomizado abarca manifestaciones neurológicas asociadas a la depresión del flap cutáneo y se distingue del síndrome postraumático por su reversibilidad con el tratamiento reparador del defecto craneano. El coma no es una forma habitual de presentación. Comunicamos un caso de presentación atípica en un hombre de 36 años de edad con antecedente de craniectomía descompresiva, que presentó un cuadro de deterioro neurológico profundo atribuible al síndrome del trefinado, el cual revirtió tras la craneoplastía. En la fisiopatología del síndrome intervienen trastornos cerebrovasculares, metabólicos, hidrodinámicos del líquido cefalorraquídeo e hiperdinamismo de las estructuras encefálicas. El gold standard terapéutico es la craneoplastía. Se requieren estudios de mayor peso estadístico para determinar el tiempo quirúrgico apropiado.

The syndrome of the trephined or craniectomized is commonly referred as neurological manifestations associated to skin flap depression and reversible after craneoplasty, which allows its differentiation from post-traumatic syndrome. We present the case of a male patient, 36 years old, with history of decompressive craniectomy. He evolved with sudden neurological worsening associated to syndrome of the trephined and recovery after craneoplasty. Physiopathology of the syndrome involves cerebrovascular, metabolic and cerebrospinal fluid hydrodynamic disturbances as well as parenchymal hyperdynamic mechanisms. Cranioplasty is the gold standard treatment. Still, studies with statistical power are needed to assess correct surgical timing.

Síndrome do trefinado: relato de caso / Syndrome of Trephined: A Case Report / Syndrome of Trephined: a case report

Síndrome do trefinado é atualmente uma complicação comum na neurotraumatologia, sendo descrita como uma síndrome na qual ocorre deterioração neurológica acompanhada de sinais e sintomas após a remoção de uma parte considerável de osso do crânio, assim como ocorre na hemicraniectomia. Neste artigo, juntamente com a revisão de literatura, será relatado o caso de um paciente adulto, vítima de acidente automobilístico, com história de traumatismo cranioencefálico (TCE) grave que foi submetido à craniectomia terapêutica, cursando com a síndrome do trefinado.

"Syndrome of the Trephined" or "Sinking Skin Flap Syndrome" is an usual syndrome in which neurological deterioration occurs following removal of a large skull bone flap (for example, in descompressive craniectomy). In this article, we will report the case of a 24 years old male, victim of an automobile accident with severe traumatic brain injury (TBI), which developed the Syndrome of the Trephined.

Cranioplastia externa para a síndrome do trefinado ­ nota técnica / External Cranioplasty for the Syndrome of Trephined ­ Technical Note

A craniectomia descompressiva (CD) é método cirúrgico amplamente utilizado para tratar a hipertensão intracraniana. Entre as complicações decorrentes da CD, a hidrocefalia é uma das mais frequentes, ocorrendo em até 30% dos casos. A implantação de derivação liquórica, necessária emalguns casos de hidrocefalia, resulta em agravamento da depressão do couro cabeludo, que ocorre após CD ­ síndrome do trefinado (ST). A realização de cranioplastia convencional é inviável em algumas situações, como ST com derivação liquórica, que não melhora após ligadura ou aumento de pressão do sistema, ou ST com depressão acentuada do couro cabeludo. Nestes casos, propomos uma nova técnica que foi aplicada em quatro casos e que consiste na confecção de uma prótese temporária com material gessado ou polimetilmetacrilato para se eliminar o efeito da pressão atmosférica. Em todos os casos, houve melhora da ST.

The decompressive craniectomy (DC) is a surgical method widely used to treat intracranial hypertension. Among the complications of CD, hydrocephalus is one of the most frequently occurring in up to 30% of cases. The implantation of CSF shunt, required in some cases of hydrocephalus results in worsening of the scalp depression, which occurs after CD ­ syndrome of trephined (ST). The performance of conventional cranioplasty is impossible in some situations, such as ST with CSF shunt that does not improve after ligation or increment of system pressure or ST with severe depression of the scalp. In these cases, we propose a new technique that has been applied in four cases and consists in molding a temporary prosthesis with cast material or polymethylmetacrilate to eliminate the effect of atmospheric pressure. In all cases, there was improvement in ST.

Craniectomía descompresiva en el trauma encefalocraneano grave: factores pronósticos y complicaciones / Decompressive craniectomy in severe traumatic brain injury: prognostic factors and complications

RESUMEN Objetivo: Análisis de las características clínicas, las complicaciones y los factores asociados al pronóstico de los pacientes con trauma encefalocraneano grave en los que se realizó craniectomía descompresiva. Métodos: Estudio retrospectivo de los pacientes asistidos en una Unidad de Cuidados Intensivos, con trauma encefalocraneano grave en los que se realizó craniectomía descompresiva, entre los años 2003 y 2012. Se siguieron los pacientes hasta el egreso de la unidad de cuidados intensivos, analizándose sus características clínico-tomográficas, las complicaciones y los factores asociados al pronóstico (análisis uni y multivariado). Resultados: Se estudiaron 64 pacientes. Se realizó craniectomía descompresiva primaria y lateral en la mayoría de los pacientes. Se halló una alta incidencia de complicaciones (78% neurológicas y 52% no neurológicas). 42 pacientes (66%) presentaron mala evolución y 22 (34%) tuvieron una buena evolución neurológica. De los pacientes que sobrevivieron, el 61% tuvo una buena evolución neurológica. En el análisis univariado, los factores asociados significativamente con mala evolución neurológica fueron: la hipertensión intracraneana post-craniectomía descompresiva, la mayor gravedad y el peor estado neurológico al ingreso. En el análisis multivariado, solo la hipertensión intracraneana post-craniectomía descompresiva se asoció significativamente con mala evolución. Conclusión: Se trata de un grupo de pacientes muy grave, de difícil manejo, con elevada morbimortalidad, donde la hipertensión intracraneana es un factor principal de mala evolución. .

ABSTRACT Objective: To analyze the clinical characteristics, complications and factors associated with the prognosis of severe traumatic brain injury among patients who undergo a decompressive craniectomy. Methods: Retrospective study of patients seen in an intensive care unit with severe traumatic brain injury in whom a decompressive craniectomy was performed between the years 2003 and 2012. Patients were followed until their discharge from the intensive care unit. Their clinical-tomographic characteristics, complications, and factors associated with prognosis (univariate and multivariate analysis) were analyzed. Results: A total of 64 patients were studied. Primary and lateral decompressive craniectomies were performed for the majority of patients. A high incidence of complications was found (78% neurological and 52% nonneurological). A total of 42 patients (66%) presented poor outcomes, and 22 (34%) had good neurological outcomes. Of the patients who survived, 61% had good neurological outcomes. In the univariate analysis, the factors significantly associated with poor neurological outcome were postdecompressive craniectomy intracranial hypertension, greater severity and worse neurological state at admission. In the multivariate analysis, only postcraniectomy intracranial hypertension was significantly associated with a poor outcome. Conclusion: This study involved a very severe and difficult to manage group of patients with high morbimortality. Intracranial hypertension was a main factor of poor outcome in this population. .

The influence of decompressive craniectomy on the development of hydrocephalus: a review / A influência da craniotomia descompressiva no desenvolvimento de hidrocefalia: uma revisão

Decompressive craniectomy (DC) is widely used to treat intracranial hypertension following traumatic brain injury (TBI) or cerebral vascular disease. Many studies have discussed complications of this procedure, and hydrocephalus is a common complication of DC. To further evaluate the relationship between DC and hydrocephalus, a review of the literature was performed. Numerous complications may arise after DC, including contusion or hematoma expansion, epilepsy, herniation of the cortex through a bone defect, CSF leakage through the scalp incision, infection, subdural effusion, hydrocephalus and “syndrome of the trephined”. Several hydrocephalus predictors were identified; these included DC, distance from the midline, hygroma, age, injury severity, subarachnoid or intraventricular hemorrhage, delayed time to craniotomy, repeated operation, and duraplasity. However, results differed among studies. The impact of DC on hydrocephalus remains controversial.

A craniectomia descompressiva (CD) é amplamente utilizada para tratar a hipertensão intracraniana após trauma craniencefálico (TC) ou doença cerebrovascular. Vários estudos discutem as complicações deste procedimento, sendo a hidrocefalia uma das complicações mais frequentes. Fizemos uma revisão da literatura para avaliar a relação entre a CD e a hidrocefalia. Podem ocorrer numerosas complicações após a CD, incluindo aumento de volume por contusão ou hematoma, epilepsia e herniação do cortex cerebral através do acesso ósseo. Fístulas liquóricas através a incisão no couro cabeludo, infecções, hematomas subdurais, hidrocefalia e a “síndrome pós-trepanação”. Foram identificados vários fatores preditivos de hidrocefalia: a distância da CD em relação à linha média, a ocorrência de higroma, a idade, a gravidade da lesão, a hemorragia subaracnóidea ou intraventricular, o tempo decorrido até a craniectomia, as reoperações e o uso de plástica com dura-máter. Entretanto, há divergências entre os autores e o impacto da CD na hidrocefalia continua controvertido.

Evaluation of prognostic factors of decompressive craniectomy in the treatment of severe traumatic brain injury / Avaliação dos fatores prognósticos da craniectomia descompressiva no tratamento do traumatismo cranioencefálico grave

OBJECTIVE: to determine predictive factors for prognosis of decompressive craniectomy in patients with severe traumatic brain injury (TBI), describing epidemiological findings and the major complications of this procedure. METHODS: we conducted a retrospective study based on analysis of clinical and neurological outcome, using the extended Glasgow outcome in 56 consecutive patients diagnosed with severe TBI scale treated in the emergency department from February 2004 to July 2012. The variables assessed were age, mechanism of injury, presence of pupillary changes, Glasgow coma scale (GCS) score on admission, CT scan findings (volume, type and association of intracranial lesions, deviation from the midline structures and classification in the scale of Marshall and Rotterdam). RESULTS: we observed that 96.4% of patients underwent unilateral decompressive craniectomy (DC) with expansion duraplasty, and the remainder to bilateral DC, 53.6% of cases being on the right 42.9% on the left, and 3.6% bilaterally, with predominance of the fourth decade of life and males (83.9%). Complications were described as transcalvarial herniation (17.9%), increased volume of brain contusions (16.1%) higroma (16.1%), hydrocephalus (10.7%), swelling of the contralateral lesions (5.3%) and CSF leak (3.6%). CONCLUSION: among the factors studied, only the presence of mydriasis with absence of pupillary reflex, scoring 4 and 5 in the Glasgow Coma Scale, association of intracranial lesions and diversion of midline structures (DML) exceeding 15mm correlated statistically as predictors of poor prognosis. .

OBJETIVO: determinar fatores preditivos de prognóstico da craniectomia descompressiva, em pacientes com traumatismo cranioencefálico grave (TCE) descrevendo achados epidemiológicos e as principais complicações do método. MÉTODOS: estudo retrospectivo mediante análise da evolução clínica e neurológica, utilizando a escala estendida de resultados de Glasgow em 56 pacientes consecutivos atendidos no Serviço de Emergência no período de fevereiro de 2004 a julho de 2012, diagnosticados com TCE grave. Os fatores avaliados foram a idade, o mecanismo de trauma, a presença de alterações pupilares, a pontuação na escala de coma de Glasgow (ECG) à admissão, achado tomográfico (volume, tipo e associação de lesões intracranianas, desvio das estruturas da linha média e classificação na escala de Marshall e Rotterdam). RESULTADOS: observou-se que 96,4% dos casos foram submetidos à craniectomia descompressiva (CD) unilateral com duroplastia de expansão e o restante, CD bilateral, sendo 53,6% dos casos à direita, 42,9% à esquerda e 3,6% bilateralmente, com predomínio até a quarta década de vida e sexo masculino (83,9%). As complicações descritas foram a herniação transcalvárica (17,9%), aumento do volume de contusões cerebrais (16,1%), higroma (16,1%), hidrocefalia (10,7%), aumento de volume de lesões contralaterais (5,3%) e fístula liquórica (3,6%). CONCLUSÃO: entre os fatores estudados, apenas a presença de midríase com ausência de reflexo fotomotor, pontuação 4 e 5 na escala de coma de Glasgow, associação de lesões intracranianas e desvio de estruturas da linha mediana (DLM) superior a 15mm correlacionaram-se estatisticamente como fatores preditivos de prognóstico ...

Asymmetric optic nerve sheath diameter as an outcome factor following cranioplasty in patients harboring the 'syndrome of the trephined' / Assimetria do diametro da bainha do nervo optico como fator prognostico apos cranioplastia em pacientes portadores da 'sindrome do trefinado'

Decompressive craniectomy (DC) is gaining an increasing role in the neurosurgical treatment of intractable intracranial hypertension, but not without complications. A rare complication is the “syndrome of the trephined” (ST). It occurs when the forces of gravity overwhelm intracranial pressures, leading the brain to become sunken. Objective To determine the usefulness of asymmetric optic nerve sheath diameter (ONSD) as an outcome factor after cranioplasty. Method We followed-up 5 patients submitted to DC and diagnosed with ST. All were submitted to brain MRI to calculate the ONSD. Results Only two patients presented an asymmetric ONSD, being ONSD larger at the site of craniectomy. Surprisingly these patients had a marked neurological improvement after cranioplasty. They became independent a week after and statistically earlier than others. Conclusion It is presumed that the presence of an asymmetric ONSD in trephined patients is an independent factor of good outcome after cranioplasty. .

A craniectomia descompressiva (CD) tem papel fundamental no tratamento da hipertensão intracraniana refratária, mas não é isenta de complicações. Uma complicação rara é a “síndrome do trefinado” (ST). Ela ocorre quando as forças gravitacionais se sobrepõem à pressão intracraniana. Objetivo Determinar a utilidade do diâmetro da bainha do nervo óptico (DBNO) como fator prognóstico após cranioplastia. Método Foram acompanhados 5 pacientes trefinados portadores da ST. Estes pacientes foram submetidos à ressonância magnética com medida do diâmetro da bainha do nervo óptico (DBNO). Resultados Dois pacientes apresentaram uma assimetria do DBNO, sendo o diâmetro maior do lado craniectomizado. Para nossa surpresa estes evoluíram melhor do que os que apresentavam o DBNO simétrico. Estes pacientes se tornaram independentes uma semana após, e estatisticamente mais cedo do que os outros. Conclusão Há evidências de que a assimetria do DBNO sirva como fator de bom prognóstico após cranioplastia no pacientes portadores da ST. .

Dissociated Horizontal Deviation after Traumatic Brain Injury

A 4-year-old boy visited the hospital with exotropia after brain hemorrhage caused by trauma. He had undergone decompressive craniectomy and cranioplasty 18 months prior to presentation at our hospital. An alternate prism cover test showed more than 50 prism diopters (PD) of left exotropia when he was fixing with the right eye and 30 PD of right exotropia when he was fixing with the left eye at near and far distance. On the Hirschberg test, 60 PD of left exotropia was noted in the primary position. Brain computerized tomography imaging performed 18 months prior showed hypodense changes in the right middle cerebral artery and anterior cerebral artery territories. Subfalcian herniation was also noted secondary to swelling of the right hemisphere. The patient underwent a left lateral rectus muscle recession of 7.0 mm and a left medial rectus muscle resection of 3.5 mm. Three weeks after the surgery, the Hirschberg test showed orthotropia. On alternate prism cover testing, 8 PD of left exotropia and 8 PD of right esotropia were noted at distance. We report a patient who developed dissociated horizontal deviation after right subfalcian subdural hemorrhage caused by trauma.