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Thomas Sauvigny, Jennifer Göttsche, Patrick Czorlich, Eik Vettorazzi, Manfred Westphal, and Jan Regelsberger

OBJECTIVE

Decompressive craniectomy (DC) is an established part of treatment in patients suffering from malignant infarction of the middle cerebral artery (MCA) or traumatic brain injury (TBI). However, no clear evidence for intracranial pressure (ICP)-guided therapy after DC exists. The lack of this evidence might be due to the frequently used, but simplified threshold for ICP of 20 mm Hg, which determines further therapy. Therefore, the objective of this study was to evaluate this threshold's accuracy and to investigate the course of ICP values with respect to neurological outcome.

METHODS

Data on clinical characteristics and parameters of the ICP course on the intensive care unit were collected retrospectively in 102 patients who underwent DC between December 2007 and April 2014 at the authors' institution. The postoperative ICP course in the first 168 hours was recorded and analyzed. From these findings, ICP thresholds discriminating favorable from unfavorable outcome were calculated using conditional inference tree analysis. Additionally, survival analysis was performed using the Kaplan-Meier method. Prognostic factors were assessed via univariate analysis and multivariate logistic regression. Favorable outcome was defined as a score of 0–4 on the modified Rankin Scale.

RESULTS

Multivariate logistic regression revealed that anisocoria, diagnosis, and ICP values differed significantly between the outcome groups. ICP values in the favorable and unfavorable outcome groups differed significantly (p < 0.001), while the mean ICP of both groups lay below the limit of 20 mm Hg (17.5 and 11.5 mm Hg, respectively). These findings were reproduced when analyzing the underlying pathologies of TBI and MCA infarction separately. Based on these findings, optimized time-dependent threshold values were calculated and found to be between 10 and 17 mm Hg. These values significantly distinguished favorable from unfavorable outcome and predicted 30-day mortality (p < 0.001).

CONCLUSIONS

This study systematically evaluated ICP levels in a long-term analysis after DC and provides new, surprisingly low, time-dependent ICP thresholds for these patients. Future trials investigating the benefit of ICP-guided therapy should take these thresholds into consideration and validate them in further patient cohorts.

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Pedram Emami, Patrick Czorlich, Friederike S. Fritzsche, Manfred Westphal, Johannes M. Rueger, Rolf Lefering, and Michael Hoffmann

OBJECTIVE

Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI.

METHODS

A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIShead) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIShead score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0–15 years old) and adults (16–55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale.

RESULTS

A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240–5.435) and fixed pupils (OR 4.197, 95% CI 3.271–5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282–3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421–0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively).

CONCLUSIONS

This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.

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Klaus Christian Mende, Mathias Gelderblom, Cindy Schwarz, Patrick Czorlich, Nils Ole Schmidt, Eik Vettorazzi, Jan Regelsberger, Manfred Westphal, and Tammam Abboud

OBJECTIVE

The aim of this prospective study was to investigate the value of somatosensory evoked potentials (SEPs) in predicting outcome in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH).

METHODS

Between January 2013 and January 2015, 48 patients with high-grade SAH (Hunt and Hess Grade III, IV, or V) who were admitted within 3 days after hemorrhage were enrolled in the study. Right and left median and tibial nerve SEPs were recorded on Day 3 after hemorrhage and recorded again 2 weeks later. Glasgow Outcome Scale (GOS) scores were determined 6 months after hemorrhage and dichotomized as poor (Scores 1–3) or good (Scores 4–5). Results of SEP measurements were dichotomized (present or missing cortical responses or normal or prolonged latencies) for each nerve and side. These variables were summed and tested using logistic regression and a receiver operating characteristic curve to assess the value of SEPs in predicting long-term outcome.

RESULTS

At the 6-month follow-up visit, 29 (60.4%) patients had a good outcome, and 19 (39.6%) had a poor outcome. The first SEP measurement did not correlate with clinical outcome (area under the curve [AUC] 0.69, p = 0.52). At the second measurement of median nerve SEPs, all patients with a good outcome had cortical responses present bilaterally, and none of them had bilateral prolonged latencies (p = 0.014 and 0.003, respectively). In tibial nerve SEPs, 7.7% of the patients with a good GOS score had one or more missing cortical responses, and bilateral prolonged latencies were found in 23% (p = 0.001 and 0.034, respectively). The second measurement correlated with the outcome regarding each of the median and tibial nerve SEPs and the combination of both (AUC 0.75 [p = 0.010], 0.793 [p = 0.003], and 0.81 [p = 0.001], respectively).

CONCLUSIONS

Early SEP measurement after SAH did not correlate with clinical outcome, but measurement of median and tibial nerve SEPs 2 weeks after a hemorrhage did predict long-term outcome in patients with high-grade SAH.

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Patrick Czorlich, Theresa Krätzig, Nikolas Kluge, Christos Skevas, Volker Knospe, Martin Stephan Spitzer, Marc Dreimann, Klaus Christian Mende, Manfred Westphal, and Sven Oliver Eicker

OBJECTIVE

Perioperative visual loss (POVL) is a rare but serious complication in surgical disciplines, especially in spine surgery. The exact pathophysiology of POVL remains unclear, but elevated intraocular pressure (IOP) is known to be part of it. As POVL is rarely described in patients undergoing intracranial or intradural surgery, the aim of this study was to investigate the course of IOP during neurosurgical procedures with opening of the dura mater and loss of CSF.

METHODS

In this prospective, controlled trial, 64 patients fell into one of 4 groups of 16 patients each. Group A included patients undergoing spine surgery in the prone position, group B patients had intracranial procedures in the prone position, and group C patients were treated for intracranial pathologies in a modified lateral position with the head rotated. In groups A–C, the dura was opened during surgery. Group D patients underwent spine surgeries in the prone position with an intact dura. IOP was measured continuously pre-, peri-, and postoperatively.

RESULTS

In all groups, IOP decreased after induction of anesthesia and increased time dependently after final positioning for the operation. The maximum IOP in group A prior to opening of the dura was 28.6 ± 6.2 mm Hg and decreased to 23.44 ± 4.9 mm Hg directly after dura opening (p < 0.0007). This effect lasted for 30 minutes (23.5 ± 5.6 mm Hg, p = 0.0028); after 60 minutes IOP slowly increased again (24.5 ± 6.3 mm Hg, p = 0.15). In group B, the last measured IOP before CSF loss was 28.1 ± 5.0 mm Hg and decreased to 23.5 ± 6.1 mm Hg (p = 0.0039) after dura opening. A significant IOP decrease in group B lasted at 30 minutes (23.6 ± 6.0 mm Hg, p = 0.0039) and 60 minutes (23.7 ± 6.0 mm Hg, p = 0.0189). In group C, only the lower eye showed a decrease in IOP up to 60 minutes after loss of CSF (opening of dura, p = 0.0007; 30 minutes, p = 0.0477; 60 minutes, p = 0.0243). In group D (control group), IOP remained stable throughout the operation after the patient was prone.

CONCLUSIONS

This study is the first to demonstrate that opening of the dura with loss of CSF during neurosurgical procedures results in a decrease in IOP. This might explain why POVL predominantly occurs in spinal but rarely in intracranial procedures, offers new insight to the pathophysiology of POVL, and provides the basis for further research and treatment of POVL.

German Clinical Trials Register (DRKS) no.: DRKS00007590 (drks.de)