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ABSTRACT: When treating patients with a spontaneous supratentorial massive (≥ 70 ml) intracerebral hemorrhage (ICH), the results of surgery are gloomy. A worsening pupil response has been observed in patients preoperatively, despite blood pressure control and diuretic administration. Because open surgery needs time for decompression to occur, the authors conducted a prospective randomized study to determine whether patients who have suffered a massive ICH can benefit from a more urgently performed decompressive procedure.
Overall, 36 eligible patients admitted 6 or fewer hours post-ictus were enrolled in the study. In Group A, 12 patients underwent CT-based hematoma puncture and partial aspiration in the emergency department (ED) and subsequent evacuation via a craniectomy; in Group B, 24 patients underwent hematoma evacuation via a craniectomy only. Pupil responses were categorized into 5 grades (Grade 0, bilaterally fixed; Grade 1, unilaterally fixed with the fixed pupil > 7 mm; Grade 2, unilaterally fixed with the fixed pupil ≤ 7 mm; Grade 3, a unilaterally sluggish response; and Grade 4, a bilaterally brisk response). Grades were obtained on admission, at surgical decompression (defined as the point at which liquid hematoma began to flow out in Group A and at dural opening in Group B), and at completion of craniectomy. The Barthel Scale was used to assess survivors' functional outcome at 12 months. Comparisons were made between Groups A and B. Logistic regression analysis was used to evaluate the positive likelihood ratio of all variables for survival and function (Barthel Scale score of ≥ 35 at 12 months).
Decompressive surgery was undertaken approximately 60 minutes earlier in Group A than B. A worsening pupil reflex before decompression was observed in no Group A patient and in 9 Group B patients. At the time of decompression pupil response was better in Group A than B (p < 0.05). Although only approximately one-third of the hematoma volume documented on initial CT scanning had been drained before the craniectomy in Group A, when partial aspiration was followed by craniectomy, better pupil-response results were obtained in Group A at the completion of craniectomy, and survival rate and 12-month Barthel Scale score were better as well (p < 0.05). Logistic regression analysis revealed that one variable, a minimum pupil grade of 3 at the time of decompression, had the highest predictive value for survival at 12 months (8.0, 95% CI 2.0-32.0), and a pupil grade of 4 at the same time was the most valuable predictor of a Barthel Scale score of 35 or greater at 12 months (15.0, 95% CI 1.9-120.9).
Patients with massive spontaneous supratentorial ICHs may benefit from more urgent surgical decompression. The results of logistic regression analysis implied that, to improve long-term functional outcome, decompression should be performed in patients before herniation occurs. Due to the fact that most of these patients have signs of herniation when presenting to the ED and because conventional surgical decompression requires time to take effect, this combination of surgical treatment provides a feasible and effective surgical option.
Journal of Neurosurgery 07/2012; 117(3):566-73. DOI:10.3171/2012.5.JNS111611 · 3.74 Impact Factor
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ABSTRACT: OBJECTS: The aim of the authors is to derive a safe, effective and feasible symptom-driven CT rule in fully conscious children ≥3 years with symptoms after head trauma, based on time-framed clinical course, radiological findings, outcome measures and prognosis of patients. METHODS: Fully conscious but symptomatic children ≥3 years after head injury (1997-2010) with CT performance ≤2 h since injury were included in the study. Additional exclusion criteria were set for patient selection. Evolution of clinical symptoms of patients in 24 h since injury was the focus in current study. Clinical data were extracted from standardised medical records on admission and observation charts. RESULTS: Data of 1897 eligible cases were retrospectively reviewed. Traumatic brain injury (TBI) was revealed radiologically in 73 cases (3.8%). Eight cases underwent surgery. Recursive partitioning analysis identified the following factors in the CT rule: any delayed headache commenced between 4 and 10 h since injury; significantly worsening headaches present between 2 and 12 h since injury; vomiting between 6 and 12 h since injury; and headache without significant changes persisted ≥12 h since injury. It has a sensitivity of 100% (95% CI 95.0% to 100.0%) and specificity of 72.1% (95% CI 70.0% to 74.1%) to predict cases with TBI. CONCLUSIONS: A symptom-driven CT rule has been derived to identify cases at high risk of having TBI in fully conscious, but symptomatic children with mild closed head injury. To be practical, an additional observation rule is added.
Emergency Medicine Journal 02/2012; 30(1). DOI:10.1136/emermed-2011-200525 · 1.84 Impact Factor
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ABSTRACT: Diffuse axonal injury (DAI) is a frequent form of traumatic brain injury, and is usually associated with long-lasting neurological impairments. A new experimental model was developed in the present study to induce DAI in rats by combining low linear and angular accelerations. In most clinical scenarios, DAI is caused by these two forms of acceleration in combination. In the injury-producing facility described here, the rat rotated instantly after it had sustained the impact that produced linear acceleration. Rats rotated rapidly 90 degrees in the coronal plane at a peak angular acceleration of 137 +/- 12 krad/sec(2) with a duration of 33.7 +/- 1.2 msec. The linear acceleration was applied to the rat's head by dropping a 450 g weight from a height of 0.9 m. Rats exposed to the combined accelerations took significantly longer to regain consciousness (11.9 +/- 3.6 min) than control rats (p < 0.01) or rats subjected to purely angular or linear acceleration (p < 0.01). Although macroscopic damage was observed in all brain-injured animals, axonal damage and hemorrhagic tissue tears were only noted in the animals sustaining the combined accelerations. All rats survived the purely linear or angular acceleration, whereas the mortality rate reached 21.7% following the combined accelerations. These results show that this model is capable of reproducing the major histological and neurological changes that are associated with DAI, and that the combination of low linear and angular accelerations can produce non-linear and synergistic effects to induce moderate/severe DAI.
Journal of neurotrauma 04/2010; 27(4):707-19. DOI:10.1089/neu.2009.1071 · 3.71 Impact Factor