Need For Neurosurgical Procedures Research Articles

The impact of helmet use on neurosurgical care and outcomes after pediatric all-terrain vehicle and dirt bike crashes: a 10-year single-center experience.

All-terrain vehicle (ATV) and dirt bike crashes frequently result in traumatic brain injury. The authors performed a retrospective study to evaluate the role of helmets in the neurosurgical outcomes of pediatric patients involved in ATV and dirt bike crashes who were treated at their institution during the last decade. The authors analyzed data on all pediatric patients involved in ATV or dirt bike crashes who were evaluated at a single regional level I pediatric trauma center between 2010 and 2019. Patients were excluded if the crash occurred in a competition (n = 70) or if helmet status could not be determined (n = 18). Multivariable logistic regression was used to analyze the association of helmet status with the primary outcomes of 1) neurosurgical consultation, 2) intracranial injury (including skull fracture), and 3) moderate or severe traumatic brain injury (MSTBI) and to control for literature-based, potentially confounding variables. In total, 680 patients were included (230 [34%] helmeted patients and 450 [66%] unhelmeted patients). Helmeted patients were more frequently male (81% vs 66%). Drivers were more frequently helmeted (44.3%) than passengers (10.5%, p < 0.001). Head imaging was performed to evaluate 70.9% of unhelmeted patients and 48.3% of helmeted patients (p < 0.001). MSTBI (8.0% vs 1.7%, p = 0.001) and neurosurgical consultation (26.2% vs 9.1%, p < 0.001) were more frequent among unhelmeted patients. Neurosurgical injuries, including intracranial hemorrhage (16% vs 4%, p < 0.001) and skull fracture (18% vs 4%, p < 0.001), were more common in unhelmeted patients. Neurosurgical procedures were required by 2.7% of unhelmeted patients. One helmeted patient (0.4%) required placement of an intracranial pressure monitor, and no other helmeted patients required neurosurgical procedures. After adjustment for age, sex, driver status, vehicle type, and injury mechanism, helmet use significantly reduced the odds of neurosurgical consultation (OR 0.250, 95% CI 0.140-0.447, p < 0.001), intracranial injury (OR 0.172, 95% CI 0.087-0.337, p < 0.001), and MSTBI (OR 0.244, 95% CI 0.079-0.758, p = 0.015). The unadjusted absolute risk reduction provided by helmet use equated to a number-needed-to-helmet of 6 riders to prevent 1 neurosurgical consultation, 4 riders to prevent 1 intracranial injury, and 16 riders to prevent 1 MSTBI. Helmet use remains problematically low among young ATV and dirt bike riders, especially passengers. Expanding helmet use among these children could significantly reduce the rates of intracranial injury and MSTBI, as well as the subsequent need for neurosurgical procedures. Promoting helmet use among recreational ATV and dirt bike riders must remain a priority for neurosurgeons, public health officials, and injury prevention professionals.

65 External Validation and Comparison of Three Predictive Tools to Identify Low-Risk Patients With Isolated Subdural Hematomas

Three predictive scoring tools have been developed to identify low-risk patients with isolated subdural hematoma and preserved consciousness: the Orlando criteria, the SafeSDH Tool, and the Brain Injury Guidelines (BIG) criteria. We aim to validate and compare these three predictive tools in a single cohort of patients with isolated subdural hematomas. We performed a retrospective chart review of patients age > 16 with GCS >= 13 with CT-confirmed isolated subdural hematomas who presented to 1 academic and 3 community EDs. The Orlando criteria, SafeSDH Tool, and BIG criteria were applied to this dataset with a primary composite outcome (CO) of neurologic deterioration (severe headache, altered mental status, seizure, intubation), neurosurgical intervention, or death. Predictors used in the Orlando tool were: hematoma size and the presence of acute-on-chronic hematoma. The Orlando criteria was applied using the maximum sensitivity cutoff of 0.0235 from the derivation study. The Orlando Tool was also tested on both neurosurgical intervention (NI) (as in the derivation study), as well as the primary CO. The SafeSDH Tool includes the following predictors: use of warfarin, use of clopidogrel, number of hematomas, hematoma thickness, GCS, and midline shift. Cutoff used for this model was 0.0432, as in derivation. BIG criteria predictors included: intoxication, hematoma size, number of hematomas, and presence of skull fracture. Patients meeting both BIG1 and BIG2 criteria were considered low risk as these patients were deemed safe for management without neurosurgical consultation in derivation. The BIG criteria were not derived via regression, so no threshold cutoff was used and area under the receiver-operator curve (AUROC) was not calculated. The validation dataset consisted of 599 patients. 173 patients (28.9%) met the composite outcome. 157 (26.2%) underwent neurosurgical intervention, 22 patients (3.7%) had clinical deterioration, and 10 patients (1.7%) died. The performance of these tools in identifying low-risk patients, their sensitivity, specificity, and AUROC are summarized in Table 1 below. This is the first study to externally validate and compare performance of the Orlando criteria, SafeSDH Tool, and BIG Criteria in identifying low-risk patients with isolated subdural hematomas using a multicenter cohort. All rules had a similarly high sensitivity in predicting need for neurosurgical procedure, neurologic decline, or death. Although specificity is limited, with prospective validation all three tools could be used to identify patients who do not require neurosurgical consultation or transfer to tertiary care centers.

Clinical Relevance of Intracranial Hemorrhage Volume in Primary and Metastatic Brain Tumors

BackgroundVenous thromboembolism occurs in approximately 15-30% of individuals with primary or metastatic brain tumors. Spontaneous intracranial hemorrhage (ICH) is also a frequent complication of brain tumors thus complicating the decision to administer therapeutic anticoagulation. We previously demonstrated that anticoagulation does not increase the risk of ICH in patients with brain metastases; however, in the setting of glioma, the risk of major ICH is 13-fold higher during exposure to anticoagulation. Absent a standardized definition of major intracranial hemorrhage, major was based on bleed volume greater than 10ml, symptoms, or requiring surgical intervention. The aim of this study was to evaluate the 10 mL bleed volume cutoff with clinical presentation and outcomes for ICH with brain tumors.MethodsIn a retrospective matched-cohort study, we evaluated patients who had primary brain tumors (n=133) and those with metastatic tumors (n=293). Matched controls were identified using a round-robin algorithm that identified best-match according to baseline demographics. A blinded review of radiographic imaging was performed and the volume of hemorrhage calculated using the ½ ABC method. Patient charts were reviewed for all surgical procedures associated with hemorrhages as well as for the presence of symptoms such as focal neurologic deficit, headache, nausea, or change in cognitive function. Statistical comparisons were performed by one sided Fisher's test and log rank test on Kaplan-Meier estimates of survival.ResultsA total of 61 out of 133 patients with primary brain tumors (45.8%), and 138 patients out of 293 patients with metastatic tumors (47%) were identified with an intracranial hemorrhage. In metastatic tumors, 87.5% (21 of 24) patients with a bleed volume of 10 mL or higher were symptomatic compared with 36% with smaller volumes (P<0.001). Similarly, glioma patients with a hemorrhage volume of 10 mL or higher was associated with the development of clinical symptoms (83% vs 17%, P<0.001). Enoxaparin administration did not influence the likelihood of symptomatology for hemorrhages > 10 mL either in glioma (P=0.3) or brain metastases (P=0.65). A threshold of 10 mL ICH also discriminated between the need for neurosurgical procedure (odds ratio 8.50, 95% CI 3.29-21.70, P<0.001). The median survival following any hemorrhage was poor (3.2 months) and was not significantly influenced by the size of hemorrhage (P=0.42).ConclusionsIntracranial bleed volume of 10 mL or more in patients with primary or metastatic brain tumors consistently correlated with clinical symptoms and need for surgical intervention. Volume assessment is an important element in assessing the clinical significance of intracranial hemorrhage and this data supports the implementation of a 10 mL volume threshold to characterize intracranial hemorrhages in cancer patients. DisclosuresNeuberg:Synta Pharmaceuticals: Other: Stock shares.

Prognostic significance of preinjury anticoagulation in patients with traumatic brain injury: A systematic review and meta-analysis.

Traumatic brain injury (TBI) is a leading cause of injury-related deaths and neurological disability globally. Considering the widespread anticoagulant use among the aging population, we aimed to perform a systematic review and meta-analysis to evaluate the prognostic significance of preinjury anticoagulation in TBI patients. This systematic review was conducted according to a predefined protocol (International Prospective Register of Systematic Reviews CRD42020192323). In compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology standards, a structured electronic database search was undertaken to identify all observational studies comparing preinjury anticoagulation with no preinjury anticoagulation in TBI patients. The primary outcome measure was overall mortality. The secondary outcome measures comprised in-hospital mortality, length of hospital stay, length of intensive care unit stay, need for neurosurgical procedure, and number of patients discharged home. All outcome data were analyzed using random effects modeling. Twelve comparative studies enrolling a total of 4,417 patients were included. Preinjury anticoagulation was associated with higher risk of overall mortality (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.63-3.50, p < 0.00001), in-hospital mortality (OR, 2.47; 95% CI, 1.56-3.93, p = 0.0001), and longer length of intensive care unit stay (mean difference, 1.06; 95% CI, 0.54-1.57; p < 0.0001) compared with no preinjury anticoagulation. No statistical difference was observed in length of hospital stay (mean difference, -2.15; 95% CI, -5.36 to 1.05, p = 0.19), need for neurosurgical procedure (OR, 1.30; 95% CI, 0.70-2.44; p = 0.41), and discharged home (OR, 0.76; 95% CI, 0.55-1.04; p = 0.09) between the two groups. Preinjury anticoagulation is a powerful prognosticator of mortality in TBI patients. This highlights the need for dedicated triage and trauma team activation protocols considering earlier intervention and more aggressive imaging in all anticoagulated patients. Future studies should focus on strategies that can potentially reduce the risk of mortality in this population. The prognostic significance of direct oral anticoagulants versus warfarin remains unanswered. Systematic review and meta-analysis of observational studies, level III.

Utilization of a Resuscitative Care Unit for Initial Triage, Management, and Disposition of Minor Intracranial Hemorrhage.

Objectives:Management of minor intracranial hemorrhage typically involves ICU admission. ICU capacity is increasingly strained, resulting in increased emergency department boarding of critically ill patients. Our objectives were to implement a novel protocol using our emergency department–based resuscitative care unit for management of management of minor intracranial hemorrhage patients in the emergency department setting, to provide timely and appropriate critical care, and to decrease inpatient ICU utilization.Design:Retrospective analysis of prospectively collected data.Setting:Single large academic medical center in the United StatesPatients:Adult patients presenting to the emergency department with management of minor intracranial hemorrhage managed via our resuscitative care unit-management of minor intracranial hemorrhage protocol from September 2017 to April 2019.Intervention:Implementation of a resuscitative care unit-management of minor intracranial hemorrhage protocol.Measurements and Main Results:Demographic data, need for vasoactive infusions in the emergency department, emergency department and hospital length of stay, emergency department disposition, and 30-day outcomes (readmission, mortality, need for neurosurgical procedure) were collected. Fifty-five patients were identified, with mean age 67.1 ± 20.0 years. Mean Glasgow Coma Scale on presentation was 14.8 ± 0.5, and 66% had a history of trauma. Locations of hemorrhage were subdural (42%), intraparenchymal (35%), subarachnoid (15%), intratumoral (7%), and intraventricular (2%). Nineteen patients (35%) were discharged from the emergency department, 22 (40%) were admitted to general care, and 14 (26%) were admitted to intensive care. In discharged patients, there was no mortality or neurosurgical interventions at 30 days. In a subgroup analysis of 36 patients with a traumatic mechanism, 18 (50%) were able to be discharged from the emergency department after management in the resuscitative care unit.Conclusions:Initial management of emergency department patients with minor intracranial hemorrhage in a resuscitative care unit appears safe and feasible and was associated with a substantial rate of discharge from the emergency department (35%) and a low rate of admission to an inpatient ICU (26%). Use of this strategy was associated with rapid initiation of ICU-level care, which may help alleviate the challenge of increasing emergency department boarding time of critically ill patients facing many institutions.

Sedation Depth is Associated with Increased Hospital Length of Stay in Mechanically Ventilated Air Medical Transport Patients: A Cohort Study

Background: Analgesics, sedatives, and neuromuscular blockers are commonly used medications for mechanically ventilated air medical transport patients. Prior research in the emergency department (ED) and intensive care unit (ICU) has demonstrated that depth of sedation is associated with increased mechanical ventilation duration, delirium, increased hospital length-of-stay (LOS), and decreased survival. The objectives of this study were to evaluate current sedation practices in the prehospital setting and to determine the impact on clinical outcomes. Methods: A retrospective cohort study of mechanically ventilated patients transferred by air ambulance to a single 812-bed Midwestern academic medical center from July 2013 to May 2018 was conducted. Prehospital sedation medications and depth of sedation [Richmond Agitation-Sedation Scale score (RASS)] were measured. Primary outcome was hospital LOS. Secondary outcomes were delirium, length of mechanical ventilation, in-hospital mortality, and need for neurosurgical procedures. Univariate analyses were used to measure the association between sedatives, sedation depth, and clinical outcomes. Multivariable models adjusted for potentially confounding covariates to measure the impact of predictors on clinical outcomes. Results: Three hundred twenty-seven patients were included. Among those patients, 79.2% of patients received sedatives, with 41% of these patients achieving deep sedation (RASS = −4). Among patients receiving sedation, 58.3% received at least one dose of benzodiazepines. Moderate and deep sedation was associated with an increase in LOS of 59% (aRR: 1.59; 95% CI: 1.40–1.81) and 24% (aRR: 1.24; 95% CI: 1.10–1.40), respectively. Benzodiazepines were associated with a mean increase of 2.9 days in the hospital (95% CI, 0.7–5.1). No association existed between either specific medications or depth of sedation and the development of delirium. Conclusions: Prehospital moderate and deep sedation, as well as benzodiazepine administration, is associated with increased hospital LOS. Our findings point toward sedation being a modifiable risk factor and suggest an important need for further research of sedation practices in the prehospital setting.

Intracranial complications of acute sinusitis in children: The role of endoscopic sinus surgery

ObjectiveTo study the role of endoscopic sinus surgery (ESS) in the management of intracranial complications of children with acute rhinosinusitis MethodsRetrospective chart review at a tertiary care pediatric hospital Main outcomesDemographics, intracranial complications, length of hospital stay (LOS), neurological sequelae, ESS, neurosurgical procedures ResultsTwenty-four children with a mean age (SD) of 12.9 years (+/-3.2) with an intracranial complication(s) of acute rhinosinusitis were identified between 2005-2016. A total of 22 were included and 15 (68%) of these were males. The most common complications were: subdural abscess (n=10), epidural abscess (n=10), meningitis (n=5), intraparenchymal abscess (n=5), and cavernous sinus thrombosis (n= 2). Neurologic symptoms included headache (n=12), hemiparesis (n=5) and aphasia (n=3). Average length of stay was 16 (+/- 9.2) days. Average follow up was 7 (+/-5.6) months. One patient had residual seizures and 1 had recurrent rhinosinusitis. Aphasia and hemiparesis resolved in all patients within 1 year. Nineteen (86%) patients had ESS within 4 days of admission. Fourteen patients (63%) had a neurosurgical procedure, 6 (27%) required more than 1 neurosurgical procedure. Six patients (27%) had concurrent neurosurgical drainage and ESS. Four patients (17%) had neurosurgical procedure followed by ESS and 3 patients (13%) were treated only by a neurosurgical procedure. Patients who underwent ESS prior to a neurosurgical procedure had significantly less risk of needing a neurosurgical intervention (OR = .02, p < .01). There was a significantly higher proportion of neurosurgical patients with positive Strep anginosus cultures compared to the ESS only group (85.7% vs 37.5%, p = .02). Studies with larger patient populations are needed to determine the role of ESS in the management of intracranial complications of children with acute rhinosinusitis. DiscussionEarly ESS may be associated with less need for neurosurgical procedures.

Blood Ethanol Levels Are Not Related to Coagulation Changes, as Measured by Thromboelastography, in Traumatic Brain Injury Patients.

Brain injury is a leading cause of death and disability in trauma patients. Ethanol (EtOH) use near the time of injury may contribute to worse outcomes in these patients by exacerbating coagulopathy. There are limited data regarding the effects of EtOH on coagulation and progression of traumatic intracranial hemorrhage (TICH). We performed a retrospective analysis of a prospective observational study of 168 trauma patients with TBI at an urban level 1 trauma center. Thromboelastography (TEG) was performed on admission and over the subsequent 48 hours. Demographic, physiologic, and outcomes data were collected. Computed tomography imaging of the head performed within the first 48 hours of admission was analyzed for progression of TICH. Thirty-six percent of patients (n= 61) had positive blood EtOH on admission (median EtOH level= 198 mg/dL [range, 16-376 mg/dL]). EtOH-positive patients were less severely injured than EtOH-negative patients (P= 0.01). Other admission demographic and physiologic variables were similar between groups. There were no significant differences in TEG values between EtOH-positive and EtOH-negative patients on admission or during the subsequent 48 hours. There were no differences in radiographic progression of hemorrhage, the need for neurosurgical procedure, or mortality between EtOH-positive and EtOH-negative patients. EtOH use near the time of traumatic injury was not associated with alterations in coagulation, as measured by traditional coagulation tests or by TEG, in patients with TICH. Furthermore, a positive blood alcohol at admission was not associated with increased mortality or need for neurosurgical procedure these patients.

The Neurointensive Care Nursery and Evolving Roles for Nursing.

Neonatal neurocritical care is an emerging subspecialty that combines the expertise of critical care medicine and neurology with that of nursing and other providers in an interprofessional team approach to care. Neurocritical care of the neonate has roots in adult and pediatric practice. It has been demonstrated that adults with acute neurologic conditions who are treated in a specialized neurocritical care unit have reduced morbidity and mortality, as well as decreased length of stay, lower costs, and reduced need for neurosurgical procedures. In pediatrics, neurocritical care has focused on various primary and secondary neurologic conditions complicating critical care that also contribute to mortality, morbidity, and duration of hospitalization. However, the concept of neurocritical care as a subspecialty in pediatric practice is still evolving, and evidence demonstrating improved outcomes is lacking. In the neonatal intensive care nursery, neurocritical care is also evolving as a subspecialty concept to address both supportive and preventive care and optimize neurologic outcomes for an at-risk neonatal patient population. To enhance effectiveness of this care approach, nurses must be prepared to appropriately recognize acute changes in neurologic status, implement protocols that specifically address neurologic conditions, and carefully monitor neurologic status to help prevent secondary injury. The complexity of this team approach to brain-focused care has led to the development of a specialized role: the neurocritical care nurse (neonatal intensive care nursery [NICN] nurse). This article will review key concepts related to neonatal neurocritical care and the essential role of nursing. It will also explore the emerging role of the NICN nurse in supporting early recognition and management of at-risk infants in this neonatal subspecialty practice.

Predictors of Positive Head CT Scan and Neurosurgical Procedures After Minor Head Trauma

There continues to be an ongoing debate regarding the utility of head CT scans in patients with a normal Glasgow Coma Scale (GCS) after minor head injury. The objective of this study is to determine patient and injury characteristics that predict a positive head CT scan or need for a neurosurgical procedure (NSP) among patients with blunt head injury and a normal GCS. Retrospective analysis of adult patients in the National Trauma Data Bank who presented to the ED with a history of blunt head injury and a normal GCS of 15. The primary outcomes were a positive head CT scan or a NSP. Multivariate logistic regression controlling for patient and injury characteristics was used to determine predictors of each outcome. Out of a total of 83,566 patients, 24,414 (29.2%) had a positive head CT scan and 3476 (4.2%) underwent a NSP. Older patients and patients with a history of fall (compared with a motor vehicle crash) were more likely to have a positive finding on a head CT scan. Male patients, African-Americans (compared with Caucasians), and those who presented with a fall were more likely to have a NSP. Older age, male gender, ethnicity, and mechanism of injury are significant predictors of a positive finding on head CT scans and the need for neurosurgical procedures. This study highlights patient and injury-specific characteristics that may help in identifying patients with supposedly minor head injury who will benefit from a head CT scan.

Computed tomography in purulent meningitis.

Of 102 patients with bacterial meningitis admitted to the Children's Hospital of Buenos Aires, 25 were selected for computed tomographic (CT) scans on the basis of altered consciousness for more than 96 hours after admission, persistent or recurrent seizures after 72 hours of antibiotic therapy, development of focal neurologic signs, increased intracranial pressure or prolonged fever. Scan findings included hydrocephalus, cerebritis, vasculitis, subdural effusion, cerebral atrophy, abscess, and ependymitis. Serial CT scans demonstrated the progression or regression of some complications. The CT scan was very useful in indicating the need for neurosurgical procedures.