Archivos de la categoría Neurotraumatología

La mitad dejan daños graves

En México la incidencia de accidentes automovilísticos que dejan traumatismo craneoencefálico es alta. Las estadísticas señalan que de cada 100 mil habitantes 200 se ven involucrados. Eduardo Nares, jefe del Servicio de Neurocirugía del Hospital Universitario de Saltillo, sostuvo que en Estados Unidos son más frecuentes.
Lo anterior se debe a que no se ha dado una precaución y estudios de patología moderna, que es muy antigua, ya que el primer accidente de tránsito sucedió hace 130 años en Nueva York, Estados Unidos.
“Si vemos todos los lastres que ha dejado esto en tan poco tiempo la situación es preocupante”.
Destacó la importancia de no dañar al paciente, ya que “en medicina no está especificada la manera de tratar a los enfermos y en ocasiones en lugar de beneficiar empeora, lo anterior porque nos quedamos con información no actualizada desde hace 10 años”1

  1. http://www.eldiariodecoahuila.com.mx/notas/2014/4/13/mitad-dejan-danos-graves-428323.asp []

CT scan in pediatric traumatic brain injury

As a general rule, in pediatric trauma patients with a Glasgow Coma Scale (GCS) less than 13, focal neurological deficits, and deteriorating consciousness should receive CT scan. However, for children with milder head injury, there is no clear consensus about requesting CT 7).

Most of the children with minor head trauma attend the emergency department nonsymptomatically or with minimal symptoms. Neurological examination is difficult in children, especially in newborns, infants (between one month and 12 months), and those under 3 years of age. Also, concern of the parents for their children and fear of malpractice litigation may force the physicians to request radiological imaging, especially the CT. The rate of requesting CT scans in children with minor head trauma (MHT) is between 5 and 50% 8).

There is a need for further prospective, multicentered studies with a large number of patients to make decision rules especially for children in this age group.

The fear of malpractice litigation should be reduced by various measures which will protect physicians such as robust departmental guidelines 9).

8) K. S. Quayle, D. M. Jaffe, N. Kuppermann et al., “Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?” Pediatrics, vol. 99, no. 5, article e11, 1997.
7) B. Simon, P. Letourneau, E. Vitorino, and J. McCall, “Pediatric minor head trauma: indications for computed tomographic scanning revisited,” Journal of Trauma, vol. 51, no. 2, pp. 231–238, 2001.
9) Gülşen I, Ak H, Karadaş S, Demır I, Bulut MD, Yaycioğlu S. Indications of brain computed tomography scan in children younger than 3 years of age with minor head trauma. Emerg Med Int. 2014;2014:248967. doi: 10.1155/2014/248967. Epub 2014 Mar 2. PubMed PMID: 24724031.

Early Decompressive craniectomy does not seem to significantly improve mortality

Early Decompressive craniectomy (DC) does not seem to significantly improve mortality in patients with refractory intracranial hypertension (ICH) compared with medical therapy (MT).

Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH.

Eleven Level 1 trauma centers provided clinical data and head computed tomographic scans for patients with a Glasgow Coma Scale (GCS) score of 13 or less and radiographic evidence of TBI excluding deaths within 48 hours. Computed tomographic scans were graded according to the Marshall classification. A propensity score to receive DC (regardless of whether DC was performed) was calculated for each patient based on patient characteristics, physiology, injury severity, GCS, severity of intracranial injury, and treatment center. Patients who actually received a DC were matched to patients with similar propensity scores who received MT for analysis. Outcomes were compared between early (<48 hours of injury) primary or secondary DC and matched controls and then between early primary DC only and matched controls.

There were 2,602 patients who met the inclusion criteria ,of whom 264 (10.1%) received DC (either primary or secondary to another cranial procedure) and 109 (5%) had a DC that was primary. Variables associated with performing a DC included sex, race, intracranial pressure monitor placement, in-house trauma attending, traumatic subarachnoid hemorrhage, midline shift, and basal cistern compression. There was no survival benefit with early primary DC compared with the controls (relative risk, 1.07; 95% confidence interval, 0.67-1.73; p = 0.77), and resource use was higher.

CONCLUSION:
Early DC does not seem to significantly improve mortality in patients with refractory ICH compared with MT. Neurosurgeons should pause before entertaining this resource-demanding form of therapy.
LEVEL OF EVIDENCE:
Therapeutic care/management, level III1

  1. Nirula R, Millar D, Greene T, McFadden M, Shah L, Scalea TM, Stein DM,
    Magnotti LJ, Jurkovich GJ, Vercruysse G, Demetriades D, Scherer LA, Peitzman A,
    Sperry J, Beauchamp K, Bell S, Feiz-Erfan I, O’Neill P, Coimbra R. Decompressive
    craniectomy or medical management for refractory intracranial hypertension: An
    AAST-MIT propensity score analysis. J Trauma Acute Care Surg. 2014
    Apr;76(4):944-55. doi: 10.1097/TA.0000000000000194. PubMed PMID: 24662856. []

Según el periódico ABC salvaron a una paciente gracias a un cráneo de plástico 3D

Enlace

http://www.abc.es/sociedad/20140327/abci-trasplante-protesis-craneo-201403262325.html

La operación, realizada en el Hospital Universitario de Utrecht, duró cerca de 23 horas y salvó la vida de una joven de 22 años de edad aquejada de una dolorosa enfermedad que engrosaba progresivamente los huesos de su cabeza, comprimiendo cada vez más su cerebro y provocando una pérdida gradual de funciones como la vista y la expresividad facial. Para evitar un desenlace que parecía irremediable, el equipo coordinado por los neurocirujanos Bon Verweij y Marvick Muradin reemplazó la totalidad de los huesos del cráneo de esta mujer, desde el nacimiento del pelo a la parte superior de su cuello y de una oreja a la otra, por un implante de plástico impreso en 3D realizado por una firma australiana.

We still lack scientific support as a first-tier therapy for the use of therapeutic hypothermia

A literature search for relevant articles in English published from year 2000 up to December 2013 found 19 studies. No signs of improvement in outcome from hypothermia were seen in the five pediatric studies. Varied results were reported in 14 studies on adult patients, 2 of which reported a tendency of higher mortality and worse neurological outcome, 4 reported lower mortality, and 9 reported favorable neurological outcome with hypothermia. The quality of several trials was low. The best-performed randomized studies showed no improvement in outcome by hypothermia-some even indicated worse outcome. TBI patients may suffer from hypothermia-induced pulmonary and coagulation side effects, from side effects of vasopressors when re-establishing the hypothermia-induced lowered blood pressure, and from a rebound increase in intracranial pressure (ICP) during and after rewarming. The difference between body temperature and temperature set by the biological thermostat may cause stress-induced worsening of the circulation and oxygenation in injured areas of the brain. These mechanisms may counteract neuroprotective effects of therapeutic hypothermia.

We still lack scientific support as a first-tier therapy for the use of therapeutic hypothermia in TBI patients for both adults and children, but it may still be an option as a second-tier therapy for refractory intracranial hypertension1

  1.  Sandestig A, Romner B, Grände PO. Therapeutic Hypothermia in Children and Adults with Severe Traumatic Brain Injury. Ther Hypothermia Temp Manag. 2014 Mar 1;4(1):10-20. Review. PubMed PMID: 24660099. []