Approccio neurochirurgico al TCE: aspetti prognostici e neuroimaging

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Bartolomeo Cirillo
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Approccio neurochirurgico al TCE: aspetti prognostici e neuroimaging Annunziato Mangiola Direttore UOC Neurochirurgia Pescara Scuola di Specializzazione

1 Approccio neurochirurgico al TCE: aspetti prognostici e neuroimaging Annunziato Mangiola Direttore UOC Neurochirurgia Pescara Scuola di Specializzazione Neurochirurgia Università G. D Annunzio Chieti- Pescara Approccio olistico nel trauma cranio-encefalico: dalla riabilitazione all'autonomia - Francavilla al Mare, giugno 2018

2 FISIOPATOLOGIA DEL SISTEMA INTRACRANICO

4 Apertura occhi Spontanea 4 Su comando 3 Al dolore 2 Assente 1 Glasgow Coma Scale Risposta verbale Orientata 5 Confusa 4 Sconnessa 3 Suoni incomprensibili 2 Assente 1 Risposta motoria Esegue ordini 6 Localizza lo stimolo 5 Flessione-retrazione 4 Flessione abnorme 3 Estensione 2 Assente 1 LIEVE MODERATO 9-12 GRAVE < 9

5 NON TUTTI I DANNI CEREBRALI AVVENGONO SOLO AL MOMENTO DEL TRAUMA LESIONE PRIMARIA LESIONE SECONDARIA

6 EMATOMA EPIDURALE ACUTO Outcome -Mortalità:10% (GCS 3-5:36%; GCS:6-8 :9%) -Mortalità:26% ematomi FCP -Outcome peggiore se associate altre lesioni intracraniche Fattori prognostici -GCS -Età -Anisocoria -Coesistenti patologie intracraniche -Tempo tra deterioramento clinico ed intervento chirurgico

7 EMATOMA SOTTODURALE ACUTO Outcome -Mortalità:40-60% -Mortalità:57-68% (GCS<8) Fattori prognostici -Età (mortalità 4 volte maggiore se >65aa) -Presenza di ipotensione e ipossia -GCS -Intervallo trauma/intervento -Caratteristiche TC : volume ematoma, shift, lesioni associate, compressione cisterne

EMATOMA INTRACEREBRALE Surgical Trial In Traumatic intracerebral Haemorrhage (STITCH): a randomised controlled trial of Early Surgery compared with Initial Conservative Treatment.

8 EMATOMA INTRACEREBRALE Surgical Trial In Traumatic intracerebral Haemorrhage (STITCH): a randomised controlled trial of Early Surgery compared with Initial Conservative Treatment. Health Technol Assess patients were randomised from 31 centres in 13 countries: 83 to Early Surgery and 87 to Initial Conservative Treatment. Six-month outcomes Patients in the Early Surgery group were 10.5% more likely to have a favourable outcome (absolute benefit), but this difference did not quite reach statistical significance because of the reduced sample size. Fifty-two (63%) had a favourable outcome with Early Surgery, compared with 45 (53%) with Initial Conservative Treatment Mortality was significantly higher in the Initial Conservative Treatment group The Rankin Scale and GOSE were significantly improved with Early Surgery using a trend analysis (p = and p = respectively). Early Surgery may be a valuable tool in the treatment of TICH, especially if the Glasgow Coma Score is between 9 and 12, as was also found in Surgical Trial In spontaneous intracerebral Haemorrhage (STICH) and Surgical Trial In spontaneous lobar intracerebral Haemorrhage (STICH II).

9 DANNO ASSONALE DIFFUSO Lesione del corpo calloso Lesione del tronco e dei peduncoli cerebellari Danno microscopico degli assoni

10 LESIONI SECONDARIE Possono svilupparsi ore o giorni dopo l evento traumatico. Causati da cascata di eventi biochimici e/o da alterazione del tono vasoregolatore con conseguenze quali: edema, iperemia, vasospasmo ed ischemia RIGONFIAMENTO CEREBRALE AUMENTO DELLA PRESSIONE INTRACRANICA

13 CRANIOTOMIA DECOMPRESSIVA

Integrated Health Care Management of Moderate to Severe TBI in Older

Current Neurology and Neuroscience Reports, 2017 Incidence of moderate

severe TBI is higher compared to younger patients Rate of female gender

14 Integrated Health Care Management of Moderate to Severe TBI in Older Patients A Narrative Review. Current Neurology and Neuroscience Reports, 2017 Incidence of moderate and severe TBI in older patients increases Incidence of moderate and severe TBI is higher compared to younger patients Rate of female gender is higher in older TBI patients Mechanism is most often falls (at home) Mortality is high and exceeds younger patients mortality

TBI prognosis calculator: A mobile application to estimate mortality and morbidity following traumatic brain injury. Clin Neurol Neurosurg. 2016 Mar;142:48-53.

15 TBI prognosis calculator: A mobile application to estimate mortality and morbidity following traumatic brain injury. Clin Neurol Neurosurg Mar;142: Of more than 100 published models, we identified the MRC CRASH trial-derived models as the most appropriate TBI prognosis tools for mobile use. These were integrated into an application we called "TBI Prognosis Calculator", which allows quick and interactive estimation of 14-days mortality and 6-months mortality and morbidity using demographic, clinical and radiologic variables

16 Models of Mortality and Morbidity in Severe Traumatic Brain Injury: An Analysis of a Singapore Neurotrauma Database. World Neurosurgery Volume 108, December 2017 Two prognostic models, NNI Clinical and NNI+, were developed. The NNI Clinical model included clinical characteristics, such as sex, age, GCS score, pupillary reactivity, and presence of major extracranial injury. The NNI+ model also included imaging characteristics and physiologic data (blood pressure, oxygen saturation, and laboratory results). Comparison with Corticosteroid Randomization After Significant Head Injury (CRASH) and Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) models was done using Akaike information criterion.

17 Clinical characteristics and prognosis of traumatic head injury following road traffic accidents admitted in ICU analysis of 694 cases European Journal of Trauma and Emergency Surgery, 2017 CT scan signs N (%) Subarachnoid hemorrhage Fracture of skull Cerebral contusion Cerebral edema Diffuse axonal injury Extradural hematoma Subdural hematoma Pneumocephalus Mass lesion Brain herniation Cerebral trunk injury Depressed skull fracture Normal CT scan Factors associated with poor outcome (Mortality and GOS II) Age > 38 years Glasgow coma scale score < 8 Subdural hematoma Development of Secondary Systemic Insults (respiratory, circulatory, and metabolic). Classification GCS on admission N % Death (GOS 1) 7.3 ± Persistent vegetative state (GOS 2) 6.3 ± Severe disability (GOS 3) 8.7 ± Moderate disability (GOS 4) 9.4 ± Good recovery (GOS 5) 10.1 ±

18 STATO DI COMA : PROGNOSI Autore N Paz. Durata Follow-up N paz. guariti Bricolo 34 2 sett. 1 anno 16 (47%) Bricolo 69 1 mese 1 anno 11 (31%) Bricolo 22 2 mesi 1 anno 6 (18%) Sazbon mese 3-52 mesi 72 (53%) Levine 93 1 mese 1 anno 48 (51.6%) Braakman mese 1 anno 59 (42.1%) Levy 25 1 mese 1 anno 2 (8%) Sato 216 > 3 mesi 1 anno 14 (6.5%) Nakazawa 1556 > 3 mesi 1 anno 18 (1,2%) Okui 1183 > 3 mesi 1 anno 14 (1,2%) Higashi 110 > 3 mesi 5 anni 8 (1,2%)

19 STATO VEGETATIVO: DOPO UN MESE Età N casi Pz. indipendenti dopo 1 aa < 20 anni (37%) anni 46 9 (20%) > 40 anni 41 0 (0%)

20 GRAZIE

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