Decompressive craniectomy following brain injury: factors important to patient outcome

Background: Decompressive craniectomy is often performed as an empirical lifesaving measure to protect the injured brain from the damaging effects of propagating oedema and intracranial hypertension. However, there are no clearly defined indications or specified guidelines for patient selection for the procedure. Aims: To evaluate outcome determinants and factors important in patientselection for the procedure. Methods: We reviewed the literature on decompressive craniectomy, including single case reports and reported case series, to identify factors affecting outcome followingthe procedure, as well as its pitfalls and associated complications. Results: Glasgow coma score of 8 and above, age less than 50 years and early intervention were found to be among the most significantdeterminants of prognosis. Conclusion: Improving patient selection for decompressive craniectomy may be expected to further improve the outcome following the procedure in severely brain injured patients

Mucormycosis: the black fungus maiming COVID-19 patients in India

The COVID-19 infection caused by the novel SARS-CoV-2 may be associated with a wide range of disease patterns, ranging from mild to life-threatening pneumonia. Mucormycosis is an emerging angioinvasive fungal infection caused by the ubiquitous filamentous fungi of the Mucorales order of the class of Zygomycetes. The prevalence of mucormycosis in India is about 80 times the prevalence in developed countries. Mucorales invade deep tissues via inhalation of airborne spores, percutaneous inoculation or ingestion. Rhino-orbito-cerebral form of mucormycosis is a relatively fatal infection and mortality rate rises to 50-85%. Extensive use of corticosteroids/monoclonal antibodies/broad-spectrum antibiotics may lead to the development/exacerbation of a preexisting fungal disease. Only amphotericin B and its lipid formulations and recently isavuconazole have been studied as first-line therapy for mucormycosis. On the contrary, posaconazole has been mainly studied as salvage therapy

Acute lung injury in paediatric intensive care: course and outcome

Introduction: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) carry a high morbidity and mortality (10-90%). ALI is characterised by non-cardiogenic pulmonary oedema and refractory hypoxaemia of multifactorial aetiology [1]. There is limited data about outcome particularly in children. Methods This retrospective cohort study of 85 randomly selected patients with respiratory failure recruited from a prospectively collected database represents 7.1% of 1187 admissions. They include those treated with High Frequency Oscillation Ventilation (HFOV). The patients were admitted between 1 November 1998 and 31 October 2000. Results: Of the 85, 49 developed acute lung injury and 47 had ARDS. There were 26 males and 23 females with a median age and weight of 7.7 months (range 1 day-12.8 years) and 8 kg (range 0.8-40 kg). There were 7 deaths giving a crude mortality of 14.3%, all of which fulfilled the Consensus I [1] criteria for ARDS. Pulmonary occlusion pressures were not routinely measured. The A-a gradient and PaO2/FiO2 ratio (median + [95% CI]) were 37.46 [31.82-43.1] kPa and 19.12 [15.26-22.98] kPa respectively. The non-survivors had a significantly lower PaO2/FiO2 ratio (13 [6.07-19.93] kPa) compared to survivors (23.85 [19.57-28.13] kPa) (P = 0.03) and had a higher A-a gradient (51.05 [35.68-66.42] kPa) compared to survivors (36.07 [30.2-41.94]) kPa though not significant (P = 0.06). Twenty-nine patients (59.2%) were oscillated (Sensormedics 3100A) including all 7 non-survivors. There was no difference in ventilation requirements for CMV prior to oscillation. Seventeen of the 49 (34.7%) were treated with Nitric Oxide including 5 out of 7 non-survivors (71.4%). The median (95% CI) number of failed organs was 3 (1.96-4.04) for non-survivors compared to 1 (0.62-1.62) for survivors (P = 0.03). There were 27 patients with isolated respiratory failure all of whom survived. Six (85.7%) of the non-survivors also required cardiovascular support.Conclusion: A crude mortality of 14.3% compares favourably to published data. The A-a gradient and PaO2/FiO2 ratio may be of help in morbidity scoring in paediatric ARDS. Use of Nitric Oxide and HFOV is associated with increased mortality, which probably relates to the severity of disease. Multiple organ failure particularly respiratory and cardiac disease is associated with increased mortality. ARDS with isolated respiratory failure carries a good prognosis in children

The aetiology, investigation and outcome of ischaemic stroke in childhood

The aetiology, investigation and outcome of ischaemic stroke were studied in a population of 128 children. Cerebrovascular abnormalities were present in the majority of children; in many cases these conformed to specific diagnostic categories, with implications for management. In contrast, previously unrecognised non-vascular risk factors for stroke were relatively rare. In particular, the prevalence of inherited prothrombotic states was no higher in children with stroke than in control populations. Although magnetic resonance angiography was useful in identifying cerebrovascular lesions, conventional cerebral angiography had a continuing and definable role in the investigation of the child with ischaemic stroke. In the investigation of outcome after ischaemic stroke a simple questionnaire investigating parents' perception of residual disability was shown to correlate well with therapists' and neuropsychological assessment. Over half the children in this population had significant residual deficits; the incidence of recurrent stroke was 17% over 5 years. A younger age at the time of stroke was associated with worse outcome. However, prognosis was not influenced by other clinical factors. In a subgroup of 38 children with lesions in the territory of a middle cerebral artery, although the location of the lesion was not related to outcome, outcome was poor in all patients who had infarcted at least 10% of intracranial volume had. Lesion size could, therefore, be used to identify patients at high risk of long term disability for future treatment trials. These findings support the view that there is a role for both acute treatment and secondary prevention in children with ischaemic stroke. This study has characterised in detail a large population of children with ischaemic stroke and has given rise to several practical recommendations about the investigation and management of such patients

Epidemiology, management and outcome of facial injuries

Dental injuries are common and the incidence of maxillofacial injuries has increased over the recent decades in Finland. Accidental injuries are the global leading cause of death among children over the age of one year and among adults under the age of 40 globally. Significant resources and costs are needed for the treatment of these patients. The prevention is the most economical way to reduce trauma rates and costs. For the prevention it is crucial to know the prevalences, incidences and risk factors related to injuries. To improve the quality of treatment, it is essential to explore the causes, trauma mechanisms and management of trauma. The above mentioned was the aim of this thesis. With a large epidemiological cohort study (5737 participants) it was possible to estimate lifetime prevalence of and risk factors for dental trauma in general population (Study I). The prevalence of dental fractures was 43% and the prevalence of dental luxations and avulsions was 14%. Male gender, a history of previous non-dental injuries, mental distress, overweight and high alcohol consumption were positively associated with the occurrence of dental injuries Study II was conducted to explore the differences in type and multiplicity of mandibular fractures in three different countries (Canada, Finland and Kuwait). This retrospective study showed that the differences in mandibular fracture multiplicity and location are based on different etiologies and demographic patterns. This data can be exploited for planning of measures to prevent traumatic facial fractures. The etiology, management and outcome of 63 pediatric skull base fracture (Study III) and 20 pediatric frontobasal fracture patients (Study IV) were explored. These retrospective studies showed that, both skull base fracture and frontobasa fracture are rare injuries in childhood and although intracranial injuries and morbidity are frequent, permanent neurological or neuropsychological deficits are infrequent. A systematic algorithm (Study V) for computer tomography (CT) image review was aimed at clinicians and radiologists to improve the assessment of patients with complex upper midface and cranial base trauma. The cohort study was cross sectional and data was collected in the Turku and Oulu University Hospitals. A novel image-reviewing algorithm was created to enhance the specificity of CT for the diagnosis of frontobasal fractures. The study showed that an image-viewing algorithm standardizes the frontobasal trauma detection procedure and leads to better control and assessment. The purpose of the retrospective subcranial craniotomy study (VI) was to review the types of frontobasal fractures and their management, complications and outcome when the fracture is approached subcranially. The subcranial approach appears to be successful and have a reasonably low complication rate. It may be recommended as the technique of choice in multiple and the most complicated frontal base fractures where the endoscopic endonasal approach is not feasible.Siirretty Doriast

Cranio-cerebral gunshot wounds

Cranio-cerebral gunshots wounds (CCGW) are the most devastating injuries to the central nervous system, especially made by high velocity bullets, the most devastating, severe and usually fatal type of missile injury to the head. Objective: To investigate and compare, using a retrospective study on five cases the clinical outcomes of CCGW. Predictors of poor outcome were: older age, delayed mode of transportation, low admission CGS score with haemodynamic instability, CT visualization of diffuse brain damage, bihemispheric, multilobar injuries with lateral and midline sagittal planes trajectories made by penetrating high velocity bullets fired from a very close range, brain stem and ventricular injury with intraventricular and/or subarachnoid hemorrhage, mass effect and midline shift, evidence of herniation and/or hematomas, high ICP and/or hypotension, abnormal coagulation states on admission or disseminated intravascular coagulation. Less harmful effects were generated by retained missiles, bone fragments with CNS infection, DAI lesions and neuronal damages associated to cavitation, seizures. Material and methods: 5 patients (4 male and 1 female), age ranged 22-65 years, with CCGW, during the period 2004-2009, caused by military conflict and accidental firing. After initial resuscitation all patients were assessed on admission by the Glasgow Coma Scale (GCS). After investigations: X-ray skull, brain CT, Angio-CT, cerebral MRI, SPECT; baseline investigations, neurological, haemodynamic and coagulability status all patients underwent surgical treatment following emergency intervention. The survival, mortality and functional outcome were evaluated by Glasgow Outcome Scale (GOS) score. Results: Referring on five cases we evaluate on a retrospective study the clinical outcome, imagistics, microscopic studies on neuronal and axonal damage generated by temporary cavitation along the cerebral bullet’s track, therapeutics, as the review of the literature. Two patients with an admission CGS 9 and 10 survived and three patients with admission CGS score of 3, with severe ventricular, brain stem injuries and lateral plane of high velocity bullets trajectories died despite treatment.Conclusion: CCGW is the most devastating type of missile injury to the head. Aggressive intensive care management in combination with early management with less aggressive meticulous neurosurgical technique, has significantly reduced the mortality and morbidity associated with these injuries, but they still remain unacceptably high. Primary prevention of these injuries remains important, the patient must be monitored closely for possible complications

PRELIMINARY FINDINGS OF A POTENZIATED PIEZOSURGERGICAL DEVICE AT THE RABBIT SKULL

The number of available ultrasonic osteotomes has remarkably increased. In vitro and in vivo studies have revealed differences between conventional osteotomes, such as rotating or sawing devices, and ultrasound-supported osteotomes (Piezosurgery®) regarding the micromorphology and roughness values of osteotomized bone surfaces. Objective: the present study compares the micro-morphologies and roughness values of osteotomized bone surfaces after the application of rotating and sawing devices, Piezosurgery Medical® and Piezosurgery Medical New Generation Powerful Handpiece. Methods: Fresh, standard-sized bony samples were taken from a rabbit skull using the following osteotomes: rotating and sawing devices, Piezosurgery Medical® and a Piezosurgery Medical New Generation Powerful Handpiece. The required duration of time for each osteotomy was recorded. Micromorphologies and roughness values to characterize the bone surfaces following the different osteotomy methods were described. The prepared surfaces were examined via light microscopy, environmental surface electron microscopy (ESEM), transmission electron microscopy (TEM), confocal laser scanning microscopy (CLSM) and atomic force microscopy. The selective cutting of mineralized tissues while preserving adjacent soft tissue (dura mater and nervous tissue) was studied. Bone necrosis of the osteotomy sites and the vitality of the osteocytes near the sectional plane were investigated, as well as the proportion of apoptosis or cell degeneration. Results and Conclusions: The potential positive effects on bone healing and reossification associated with different devices were evaluated and the comparative analysis among the different devices used was performed, in order to determine the best osteotomes to be employed during cranio-facial surgery