RESUMEN
OBJECT: The factors that contribute to periprocedural complications following cranioplasty, including patient-specific and surgery-specific factors, need to be thoroughly assessed. The aim of this study was to evaluate risk factors that predispose patients to an increased risk of cranioplasty complications and death. METHODS: The authors conducted a retrospective review of all patients at their institution who underwent cranioplasty following craniectomy for stroke, subarachnoid hemorrhage, epidural hematoma, subdural hematoma, and trauma between January 2000 and December 2011. The following predictors were tested: age, sex, race, diabetic status, hypertensive status, tobacco use, reason for craniectomy, urgency status of the craniectomy, graft material, and location of cranioplasty. The cranioplasty complications included reoperation for hematoma, hydrocephalus postcranioplasty, postcranioplasty seizures, and cranioplasty graft infection. A multivariate logistic regression analysis was performed. Confidence intervals were calculated as the 95% CI. RESULTS: Three hundred forty-eight patients were included in the study. The overall complication rate was 31.32% (109 of 348). The mortality rate was 3.16%. Predictors of overall complications in multivariate analysis were hypertension (OR 1.92, CI 1.22-3.02), increasing age (OR 1.02, CI 1.00-1.04), and hemorrhagic stroke (OR 3.84, CI 1.93-7.63). Predictors of mortality in multivariate analysis were diabetes mellitus (OR 7.56, CI 1.56-36.58), seizures (OR 7.25, CI 1.238-42.79), bifrontal cranioplasty (OR 5.40, CI 1.20-24.27), and repeated surgery for hematoma evacuation (OR 13.00, CI 1.51-112.02). Multivariate analysis was also applied to identify the variables that affect the development of seizures, the need for reoperation for hematoma evacuation, the development of hydrocephalus, and the development of infections. CONCLUSIONS: The authors' goal was to provide the neurosurgeon with predictors of morbidity and mortality that could be incorporated in the clinical decision-making algorithm. Control of a patient's risk factors and early recognition of complications may help practitioners avoid the exhaustive list of complications.
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Hidrocefalia/epidemiología , Procedimientos Neuroquirúrgicos/efectos adversos , Procedimientos de Cirugía Plástica/efectos adversos , Complicaciones Posoperatorias/epidemiología , Convulsiones/epidemiología , Infección de la Herida Quirúrgica/epidemiología , Adulto , Factores de Edad , Lesiones Encefálicas/cirugía , Femenino , Estudios de Seguimiento , Hematoma Subdural/cirugía , Humanos , Incidencia , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Grupos Raciales , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Accidente Cerebrovascular/cirugíaRESUMEN
INTRODUCTION: The variables that predispose to postcranioplasty infections are poorly described in the literature. We formulated a multivariate model that predicts the risk of infection in patients undergoing cranioplasty. METHOD: Retrospective review of all patients who underwent cranioplasty following craniectomy from January, 2000, to December, 2011. Tested predictors were age, sex, diabetic status, hypertensive status, reason for craniectomy, urgency status of craniectomy, location of cranioplasty, reoperation for hematoma, hydrocephalus postcranioplasty, and material type. A multivariate logistic regression analysis was performed. RESULTS: Three hundred forty-eight patients met the study criteria. Infection rate was 26.43% (92/348). Of these cases with infection, 56.52% (52/92) were superficial (supragaleal), 43.48% (40/92) were deep (subgaleal), and 31.52% (29/92) were present in both the supragaleal and subgaleal spaces. The predominant pathogen was coagulase-negative staphylococcus (30.43%) followed by methicillin-resistant Staphylococcus aureus (22.83%) and methicillin-sensitive Staphylococcus aureus (15.22%). Approximately 15.22% of all cultures were polymicrobial. Multivariate analysis revealed convex craniectomy, hemorrhagic stroke, and hydrocephalus to be associated with an increased risk of infection (OR = 14.41; P < 0.05, OR = 4.33; P < 0.05, OR = 1.90; P = 0.054, resp.). CONCLUSION: Many of the risk factors for infection after cranioplasty are modifiable. Recognition and prevention of the risk factors would help decrease the infection's rate.
Asunto(s)
Craneotomía/efectos adversos , Infecciones Estafilocócicas/diagnóstico , Infección de la Herida Quirúrgica/diagnóstico , Craneotomía/tendencias , Humanos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Infecciones Estafilocócicas/epidemiología , Infección de la Herida Quirúrgica/epidemiologíaRESUMEN
BACKGROUND: Stroke is a leading cause of death and disability in the United States. Despite the proven benefits of intravenous tissue plasminogen activator (IV-tPA), only a small percentage of patients who have had a stroke (3.4%-5.2%) receive this US Food and Drug Administration-approved therapy. OBJECTIVE: To prospectively assess the impact of a telestroke network on the rate of IV-tPA administration in patients with acute ischemic stroke in community hospitals. METHODS: Thomas Jefferson University Hospital has developed a telestroke system providing acute stroke care in 28 community hospitals within the region (Pennsylvania, New Jersey, and Delaware). Telemedicine consultations are delivered through Remote Presence robotic technology. RESULTS: A total of 1643 telemedicine stroke consultations were provided between January 2011 and June 2012. The mean interval from consultation request to telemedicine response was 12.0 minutes. The overall rate of IV-tPA use was 14% among all stroke consultations. A total of 237 patients (14.4%) were determined to be eligible for intravenous thrombolysis. Of those, 97% received IV-tPA. Most hospitals (82%) within the telemedicine program reported an increase in IV-tPA use (mean increase, 55%). The proportion of patients transferred to a primary stroke center after teleconsultation decreased from 44% in the first 2 quarters of 2011 to 19% in the first 2 quarters of 2012 (P < .001). CONCLUSION: Implementing a telestroke system facilitates high rates of intravenous thrombolysis in patients who have had a stroke in community hospitals within a relatively short time frame. These results are higher than the national average rate (3.4%-5.2%) and support the implementation of telestroke networks for wider access to stroke expertise in underserved regions.