Is There an Advantage to Minimizing Surgery in Scaphocephaly? A Study on Extended Strip Craniectomy Versus Extensive Cranial Vault Remodeling.

BACKGROUND: Different techniques have been described to correct scaphocephaly. In authors' institution, total cranial vault remodeling (TCVR) was the standard of care. To limit the extent of surgery and the need for transfusion, the technique was minimized to extended strip craniectomy (ESC) without helmet therapy. This retrospective study compares outcome and morbidity between ESC and TCVR. METHODS: Twenty-seven scaphocephalic patients were included. The ESC was performed in 9 patients between 2012 and 2014, and TCVR in 17 patients between 2008 and 2016. Data on blood loss and transfusion rate, duration of surgery, length of hospital stay (LOS), head circumference, and cephalic index (CI) were collected retrospectively. A cosmetic outcome score (COS) was developed to rate esthetic outcome since CI is a limited and crude measurement of cosmetic outcome. RESULTS: The LOS was identical in both groups, but duration of surgery was significantly shorter in ESC (P < 0.0001). Transfusion rate appeared higher in the TCVR group, but differences were not significant (P = 0.11). Cosmetic outcome appeared slightly worse in the ESC group, but results were not significantly different (P = 0.66). There was, however, a significant improvement in postoperative CI in the TCVR group (P < 0.0001). CONCLUSION: The only advantage of ESC was the reduced duration of surgery, but this could not prevent the need for transfusion in this group of patients. The improvement of the CI was significantly less pronounced after ESC, but the COS was not significantly worse in the ESC group. The scar and LOS were similar in both groups. Therefore, our findings indicate that minimizing TCVR to ESC without helmet therapy does not provide significant advantages.

Decision making in very severe traumatic brain injury (Glasgow Coma Scale 3-5): a literature review of acute neurosurgical management.

INTRODUCTION: Patients presenting with an early Glasgow Coma Scale (GCS) Score of 3-5 after blunt or penetrating skull-brain assaults are categorized as having sustained a very severe traumatic brain injury (vs-TBI). This category is often overlooked in literature. Impact on patients and families lives however is huge and the question "whether to surgically treat or not" frequently poses a dilemma to treating physicians. Little is known about mortality and outcome, compared to what is known for the group of severe TBI patients (s-TBI) (GCS 3-8). The main goal of this review was creating more awareness for the neurosurgical treatment of this patient group. EVIDENCE ACQUISITION: A literature search (2000-2017) was conducted discussing "severe TBI (GCS 3-8)", "(neuro)surgical management" and "outcome". Ultimately 45 out of 2568 articles were included for further analysis. EVIDENCE SYNTHESIS: Mortality rates and unfavorable outcome are high for s-TBI patients and as expected higher for vs-TBI patients. Mortality rates reach up to 100% for specific subgroups with GCS=3 and bilaterally fixed dilated pupils. Functional outcome was generally poor, but sometimes, although seldom, favorable in specific groups of vs-TBI patients after neurosurgical intervention. Factors like initial GCS, pupillary abnormalities and age seem to be associated with worse outcome. CONCLUSIONS: Overall this literature review showed high rates of unfavorable outcome and mortality for vs-TBI patients. However, some studies, reporting relatively low mortality rates, reported "good" outcome for specific groups of vs-TBI patients. It is concluded that clinical decision making, in particular those on treatment limitations, should never be taken based on the GCS alone.

Differential effects of the Glasgow Coma Scale Score and its Components: An analysis of 54,069 patients with traumatic brain injury.

INTRODUCTION: The Glasgow Coma Scale (GCS) is widely used in the assessment of clinical severity and prediction of outcome after traumatic brain injury (TBI). The sum score is frequently applied, but the differential influence of the components infrequently addressed. We aimed to investigate the contribution of the GCS components to the sum score, floor and ceiling effects of the components, and their prognostic effects. METHODS: Data on adult TBI patients were gathered from three data repositories: TARN (n=50,064), VSTR (n=14,062), and CRASH (n=9,941). Data on initial hospital GCS-assessment and discharge mortality were extracted. A descriptive analysis was performed to identify floor and ceiling effects. The relation between GCS and outcome was studied by comparing case fatality rates (CFR) between different component-profiles adding up to identical sum scores using Chi2-tests, and by quantifying the prognostic value of each component and sum score with Nagelkerke's R2 derived from logistic regression analyses across TBI severities. RESULTS: In the range 3-7, the sum score is primarily determined by the motor component, as the verbal and eye components show floor-effects at sum scores 7 and 8, respectively. In the range 8-12, the effect of the motor component attenuates and the verbal and eye components become more relevant. The motor, eye and verbal scores reach their ceiling-effects at sum 13, 14 and 15, respectively. Significant variations were exposed in CFR between different component-profiles despite identical sum scores, except in sum scores 6 and 7. Regression analysis showed that the motor score had highest R2 values in severe TBI patients, whereas the other components were more relevant at higher sum scores. The prognostic value of the three components combined was consistently higher than that of the sum score alone. CONCLUSION: The GCS-components contribute differentially across the spectrum of consciousness to the sum score, each having floor and ceiling effects. The specific component-profile is related to outcome and the three components combined contain higher prognostic value than the sum score across different TBI severities. We, therefore, recommend a multidimensional use of the three-component GCS both in clinical practice, and in prognostic studies.

The reliability of the Glasgow Coma Scale: a systematic review.

INTRODUCTION: The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS. METHODS: A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively. RESULTS: We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85%, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used. CONCLUSIONS: Only 13% of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.

Lack of Standardization in the Use of the Glasgow Coma Scale: Results of International Surveys.

The Glasgow Coma Scale (GCS) was introduced 40 years ago and has received world-wide acceptance. The GCS rates eye, motor, and verbal responses to assess the level of consciousness. Concerns have been expressed with regard to reliability and consistency of assessments. We considered that lack of standardization in application techniques and reporting of the GCS may have contributed to these concerns, and aimed to assess current procedures in its use. Questionnaire-based assessments were conducted by an online survey and during neurosurgical training courses. Overall, 616 participants were recruited, representing 48 countries and including physicians and nurses from different disciplines. Use of the GCS was reported by nearly all participants for assessment of patients with traumatic brain injury, but not for all patients with a reduced level of consciousness from other causes (78%). Major differences were found regarding the type of stimulus applied when patients do not obey commands: Nail bed pressure, supraorbital pressure, trapezius or pectoralis pinch, and sternal rub were all frequently used, whereas 25% of responders reported to never use a peripheral stimulus. Strategies for reporting the GCS varied greatly, and 35% of participants limited the reporting to a summary score. Moreover, different approaches were used when one of the components could not be assessed. Overall, the surveys have identified a general lack of standardization in assessment and reporting of the GCS. The results illustrate the need for continued education to improve reliability of assessments through guidance to a standard approach.

Adiponectin deficiency blunts hypoxia-induced mobilization and homing of circulating angiogenic cells.

Aim. We investigated the effects of adiponectin deficiency on circulating angiogenic cell (CAC) mobilization, homing, and neovascularization in the setting of acute myocardial infarction (AMI). Methods & Results. AMI was induced in wild-type (WT) (n = 10) and adiponectin knockout (Adipoq (-/-)) mice (n = 7). One week after AMI, bone marrow (BM) concentration and mobilization of Sca-1(+) and Lin(-)Sca-1(+) progenitor cells (PCs) were markedly attenuated under Adipoq (-/-) conditions, as assessed by flow cytometry. The mRNA expression of HIF-1-dependent chemotactic factors, such as Cxcl12 (P = 0.005) and Ccl5 (P = 0.025), and vascular adhesion molecules, such as Icam1 (P = 0.010), and Vcam1 (P = 0.014), was significantly lower in the infarction border zone of Adipoq (-/-) mice. Histologically, Adipoq (-/-) mice evidenced a decrease in neovascularization capacity in the infarction border zone (P < 0.001). Overall, capillary density was positively correlated with Sca-1(+) PC numbers in BM (P = 0.01) and peripheral blood (PB) (P = 0.005) and with the expression of the homing factors Cxcl12 (P = 0.013), Icam1 (P = 0.034) and Vcam1 (P = 0.014). Conclusions. Adiponectin deficiency reduced the BM reserve and mobilization capacity of CACs, attenuated the expression of hypoxia-induced chemokines and vascular adhesion molecules, and impaired the neovascularization capacity one week after AMI.