RESUMEN

Acute intracranial hypertension (AIH) is a common and tricky symptom that inflicts upon patients after traumatic brain injury (TBI). A variety of clinical options have been applied for the management of AIH, such as physiotherapy, medication, surgery and combination therapy. Specifically, controlled decompression (CDC) alleviates the extent of brain injury and reduces the incidence of a series of post-TBI complications, thereby enhancing the prognosis of patients suffering from acute intracranial hypertension. The objective of the present project is to illuminate the potential molecular mechanism that underlies the neuroprotective effects of CDC in a rat model of traumatic epidural intracranial hypertension (TEIH). Herein, we observed the functional recovery, the degree of brain edema, the level of apoptosis, the expressions of neuronal cell autophagy-related signaling pathway proteins (including Akt, p-Akt, LC3 and Beclin-1) in rat TEIH model at 24 h post-surgery. The results showed in comparison with rapid decompression (RDC), CDC reduced the degree of brain edema, diminished the level of cellular apoptosis and enhanced neurological function, and whereas the neuroprotective effect of CDC could be reversed by rapamycin (Rap). The expressions of Beclin-1 and LC3 in CDC group were significantly lower than those of RDC group, and the expression levels of these two proteins were significantly elevated after the addition of Rap. The expression of p-Akt in CDC group was considerably enhanced than RDC group. After the addition of LY294002, a PI3K/Akt pathway inhibitor, p-Akt protein expression was reduced, and the neuroprotective effect of the rats was markedly inhibited. Taken together, our data demonstrate the superior neuroprotective effect of CDC with regard to alleviating early brain edema, improving the neurological status, suppressing apoptosis and inhibiting neuronal autophagy via triggering PI3K/Akt signaling pathway.

RESUMEN

Severe traumatic brain injury (sTBI) has a high mortality and disability rate, making it a difficult issue and hot topic in neurosurgery. Controlled decompression is an important technique in the treatment of sTBI combined with intracranial hypertension, which can reduce the ischemia-reperfusion injury to the nervous tissue and intracranial vessel and can significantly lower the incidence of complications related to decompressive craniectomy. However, the effects of the controlled decompression technique have been affected by different understandings of the technique and nonstandard surgical procedures in clinical practice. For this purpose, the authors discussed the concept of controlled decompression technique, its indications and the key problems during operation so as to standardize the surgical procedures and improve the therapeutic effects of controlled decompression technique in the treatment of sTBI.

RESUMEN

Decompressive craniectomy (DC) is a major form of surgery that is used to reduce intracranial hypertension (IH), the most frequent cause of death and disability following severe traumatic brain injury (sTBI) and stroke. Our previous research showed that controlled decompression (CDC) was more effective than rapid decompression (RDC) with regard to reducing the incidence of complications and improving outcomes after sTBI; however, the specific mechanisms involved have yet to be elucidated. In the present study, we investigated the effects of CDC in regulating inflammation after IH and attempted to identify the mechanisms involved. Analysis showed that CDC was more effective than RDC in alleviating motor dysfunction and neuronal death in a rat model of traumatic intracranial hypertension (TIH) created by epidural balloon pressurization. Moreover, RDC induced M1 microglia polarization and the release of pro-inflammatory cytokines. However, CDC treatment resulted in microglia primarily polarizing into the M2 phenotype and induced the significant release of anti-inflammatory cytokines. Mechanistically, the establishment of the TIH model led to the increased expression of hypoxia-inducible factor-1α (HIF-1α); CDC ameliorated cerebral hypoxia and reduced the expression of HIF-1α. In addition, 2-methoxyestradiol (2-ME2), a specific inhibitor of HIF-1α, significantly attenuated RDC-induced inflammation and improved motor function by promoting M1 to M2 phenotype transformation in microglial and enhancing the release of anti-inflammatory cytokines. However, dimethyloxaloylglycine (DMOG), an agonist of HIF-1α, abrogated the protective effects of CDC treatment by suppressing M2 microglia polarization and the release of anti-inflammatory cytokines. Collectively, our results indicated that CDC effectively alleviated IH-induced inflammation, neuronal death, and motor dysfunction by regulating HIF-1α-mediated microglial phenotype polarization. Our findings provide a better understanding of the mechanisms that underlie the protective effects of CDC and promote clinical translational research for HIF-1α in IH.

Asunto(s)

Lesiones Traumáticas del Encéfalo , Hipertensión Intracraneal , Ratas , Animales , Microglía/metabolismo , Transducción de Señal , Inflamación/metabolismo , Antiinflamatorios/farmacología , Lesiones Traumáticas del Encéfalo/metabolismo , Hipertensión Intracraneal/tratamiento farmacológico , Hipertensión Intracraneal/metabolismo , Citocinas/metabolismo , Descompresión , Subunidad alfa del Factor 1 Inducible por Hipoxia/metabolismo

RESUMEN

Intracranial hypertension (IH) remains a common symptom of neurological diseases, and requires stepwise treatments to release intracranial pressure (ICP). In the present study, we built a rat model of epidural extreme intracranial hypertension (EEIH) and verified the effectiveness of a surgery method called controlled decompression on attenuating brain injury induced by EEIH. For the model part, we determined the level of EEIH of rats via recording ICP and cerebral perfusion pressure (CPP) and the variation tendency of survival rates, mean blood artery pressure and mean velocity (Vm) of left middle cerebral artery (LMCA) as ICP ascending. SD rats were assigned into 4 groups: Sham group, Controlled decompression group (Con group), Rapid decompression group (Rap group) and Rapid decompression + Necrostatin-1 (Nec-1) group (Rap+Nec-1 group). The results suggested that controlled decompression lowered cerebral water content, improved neurological function, and attenuated EEIH-induced inflammation response and ROS generation to a greater extent than rapid decompression. Meanwhile, controlled decompression functioned to preserve more Nissl bodies, indicating alleviated neuron injury after EEIH. Additionally, the permeability of blood brain barrier (BBB) was also safeguarded in the Con group. Western blotting (WB) and Real-time Polymerase Chain Reaction (rt-PCR) assays consistently determined lower protein and mRNA levels of necroptosis-related molecules receptor interacting protein kinase 1 (RIPK1), interacting protein kinase 3 (RIPK3) and mixed lineage kinase domain-like protein (MLKL) (WB only) in the Con and Rap+Nec-1 group. Double immunofluorescent staining found weaker fluorescence intensity of RIPK3 in the compressed cortex of the Con and Rap+Nec-1 group.

Asunto(s)

Lesiones Encefálicas , Hipertensión Intracraneal , Animales , Encéfalo , Descompresión , Necroptosis , Ratas , Ratas Sprague-Dawley

RESUMEN

Objective:To investigate the application value of pre-suture craniotomy combined with intracranial pressure monitoring in surgery for posttraumatic acute diffuse brain swelling (PADBS).Methods:One hundred and fifty-seven patients with PADBS admitted to our hospital from February 2015 to December 2019 were chosen in our study; 68 patients (control group), admitted to our hospital from February 2015 to June 2017, underwent controlled decompression under intracranial pressure monitoring; and 89 patients (treatment group), admitted to our hospital from June 2017 to December 2019, were performed pre-suture craniotomy combined with controlled decompression under intracranial pressure monitoring. The craniotomy time, brain tissue exposure time, cranial closure time, incidence of acute encephalocele, and Glasgow outcome scale (GOS) scores at 6 months after injury were retrospectively analyzed and compared between the two groups.Results:As compared with those in the control group, the patients in the treatment group had significantly longer intraoperative craniotomy time ([19.2±1.6] min vs. [15.4±1.4] min), significantly shorter exposure time of brain tissues ([18.5±2.4] min vs. [26.3±2.2] min), significantly shorter time of cranial closure ([11.2±1.5] min vs. [18.3±2.1] min), and statistically lower incidence of acute encephalocele (22.5% vs. 38.2%), P<0.05). The good prognosis rate of the treatment group (70.8%) was significantly higher than that of the control group (50.0%), and the mortality rate (6.7%) was statistically lower than that of the control group (17.6%, P<0.05). Conclusion:Pre-suture craniotomy combined with controlled decompression under intracranial pressure monitoring can shorten the time of cranial closure and brain tissue exposure, reduce the incidence of acute encephalocele, and ultimately improve the prognosis of patients with posttraumatic acute diffuse brain swelling.

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Background: Experimental evidence has indicated the benefits of intraoperative controlled decompression for the treatment of severe traumatic brain injury (sTBI). Intraoperative rapid decompression (conventional decompression) for the treatment of sTBI may result in intra- and post-operative complications. Controlled decompression may reduce these complications. Previous clinical trials in China have not yielded conclusive results regarding controlled decompression for sTBI. Therefore, we explored whether controlled decompression treatment decreases the rates of complications and improves the outcomes of patients with sTBI. Methods: We performed this randomized, controlled trial at our hospital. Patients with sTBI aged 18-75 years old were randomly (1:1) divided into controlled decompression surgery (n = 124) or rapid decompression surgery groups (n = 124). The primary outcome measures were the Extended Glasgow Outcome Scale (GOS-E) score at 6 months and 30-days all-cause mortality. The secondary outcomes were the incidences of intraoperative brain swelling, post-traumatic cerebral infarction, and delayed hematoma. Results: Compared with the rapid decompression group, the controlled decompression group had reduced 30-days all-cause mortality (18.6 vs. 30.8%, P = 0.035) and improved the 6-months GOS-E scores, and the difference was significant. In addition, the patients in the controlled decompression group had a lower intraoperative brain swelling rate (13.3 vs. 24.3%, P = 0.036), a lower delayed hematoma rate (17.7 vs. 29.0%, P = 0.048) and a relatively lower post-traumatic cerebral infarction rate (15.0 vs. 22.4%, P = 0.127) than those in the rapid decompression group. Conclusions: Our data suggest that controlled decompression surgery significantly improves sTBI outcomes and decreases the rates of sTBI-related complications. However, this was a single-hospital study, and well-designed multicenter randomized controlled trials are needed to evaluate the effects of controlled decompression surgery for the management of patients with sTBI. Clinical Trial Registration: Chinese Clinical Trial Registry; Date: 14/Dec/2013; Number: ChiCTR-TCC-13004002.

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Objective To explore the effect of cerebrospinal fluid release combined with controlled decompression under intracranial pressure monitoring on prevention of intraoperative intracranial swelling in patients with acute severe craniocerebral injury. Methods According to the inclusion and exclusion criteria, 90 patients with acute severe craniocerebral injury were randomly divided into study group (48 cases) and control group (42 cases). Patients in the study group underwent ventricular intracranial pressure probe placement, and then the standard decompressive craniectomy. During the operation, cerebrospinal fluid release combined with controlled decompression under intracranial pressure monitoring was applied to prevent brain swelling. Patients in the control group underwent standard decompressive craniectomy combined with controlled decompression to prevent brain swelling. The incidence of intraoperative brain swelling and cerebral infarction within 3 d after surgery, and the mortality within 1 month after surgery were evaluated. Prognosis was evaluated by GOS score after 3 months of follow-up. Results The brain swelling rate, cerebral infarction rate, mortality within 1 month, and Glasgow Coma Scale (GOS) score at 3 months after operation in the study group were better than those in the control group with statistical significance:10.4％(5/48) vs. 28.6％(12/42), 29.2％(14/48) vs. 64.3％(27/42), 18.8％(9/48) vs. 35.7％(15/42)], (2.83 ± 1.08) scores vs.(1.83 ± 0.76) scores, P<0.05. Conclusions Cerebrospinal fluid release combined with controlled decompression under intracranial pressure monitoring can reduce the incidence of intraoperative brain swelling and improve the prognosis of patients with acute severe craniocerebral injury.

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Objective To explore the value of controlled decompression under intracranial pressure monitoring in craniotomy of patients with severe cerebral hemorrhage.Methods One hundred and six patients with severe cerebral hemorrhage,admitted to our hospital from January 2015 to July 2018,were prospectively enrolled.These patients were divided into control group (n=5 l) and treatment group (n=55) according to their families' wishes.The patients in the control group were treated with traditional craniotomy and hematoma removal;the patients in the treatment group were treated with controlled decompression combined with craniotomy and hematoma clearance under intracranial pressure monitoring,and intracranial pressure monitoring and management were carried out after operation.The rate of bone flap acceptance during operation,incidences of complications such as re-bleeding,scalp exudation,intracranial infection and cerebral infarction after operation,rate of re-operation and Glasgow outcome scale scores 6 months after injury were compared and analyzed between the two groups.Results Five patients had midway withdrawal (2 from the control group and 3 from the treatment group),and 101 patients (49 from the control group and 52 from the treatment group) were included in the statistical analysis.The rate of bone flap acceptance in the treatment group (69.2％) was significantly higher than that in the control group (24.5％,P＜0.05).The incidences of complications such as bleeding,scalp exudation,intracranial infection and cerebral infarction (11.5％,7.7％,3.8％,and 13.5％) were significantly lower than those in the control group (30.6％,22.4％,16.3％,and 34.7％,P＜0.05).The re-operation rate (3.8％) was significantly lower than that in the control group (16.3％,P＜0.05).Good recovery rate in the treatment group (76.9％) was significantly higher than that in the control group (55.1％,P＜0.05).The mortality rate (7.7％) was significantly lower than that of the control group (22.4％,P＜0.05).Conclusion For patients with severe cerebral hemorrhage,controlled decompression under intracranial pressure monitoring combined with craniotomy and hematoma removal can significantly improve the rate of bone flap acceptance,reduce the rate of second-stage cranioplasty,reduce the incidence of complications and re-operation rate,and more effectively improve the quality of life and prognosis of patients.

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Objective To explore the application of controlled decompression under intracranial pressure (ICP) monitoring for the patients with hypertensive intracerebral hemorrhage and long-term aspirin use in the treatment with soft channel puncture and drainage.Methods This prospective study enrolled 87 patients with hypertensive intracerebral hemorrhage and long-term aspirin use from the Department of Neurosurgery,The First People's Hospital of Huzhou from February 2013 to February 2017.They were divided into a control group (43 cases) and a treatment group (44 cases) according to their wishes.The control group was treated by conventional soft channel puncture and drainage while the treatment group by controlled depression under ICP monitoring in addition to soft channel puncture drainage.Results In the treatment group,the volume ofhematoma aspiration (ICP) was (10.38±3.24) mL,accounting for about 20％ of the initial hematoma.The time for retention of endovascular drainage tube in the treatment group (90.0±4.2 h) was significantly longer than that in the control group (73.0±3.8 h),and the hematoma clearance rate in the treatment group (80.0％±1.2％) was significantly lower than that in the control group (91.0％± 1.9％) (P＜0.05).The incidences of such postoperative complications as rebleeding,scalp leachate and intracranial infection (11.4％,9.1％ and 4.5％,respectively) in the treatment group were significantly lower than in the control group (34.9％,25.6％ and 11.6％,respectively) (P＜ 0.05).The recovery rate in the treatment group (77.3％) was significantly higher than in the control group (60.5％);the mortality rate in the former (9.1％) was significantly lower than in the latter (18.6％) (P＜ 0.05).Conclusion For patients with hypertensive intracerebral hemorrhage and long-term aspirin use,controlled decompression combined with soft channel puncture drainage under ICP monitoring can effectively improve their quality of life and prognosis.

RESUMEN

Objective To explore the effect of hyperbaric oxygen combined with progressively controlled decompression on the prognosis of patients with emergency craniocerebral trauma.Methods Ninety-six patients with emergency craniocerebral trauma were selected as study subjects,and they were divided into observation group (n =50) and control group(n =46) according to the random number table.The observation group was treated by progressively controlled decompression combined with hyperbaric oxygen,while the control group was treated by standard large trauma craniotomy combined with hyperbaric oxygen.The incidence of perioperative complications,prognosis (evaluated by GOS) and activities of daily living(evaluated by ADL) were compared between the two groups.Results In the observation group,the incidence rates of perioperative acute encephalocele,delayed hematoma and postoperative cerebral infarction were 6.0％,10.0％,6.0％,respectively,which were lower than 19.6％,26.1％,21.7％ of the control group(x2 =4.031,4.255,5.069,all P ＜ 0.05).The good prognosis rate in the observation group was 62.0％,which was significantly higher than 39.1％ in the control group (x2 =5.014,P ＜ 0.05).There was no significant difference in ADL score between the two groups before treatment (t =0.347,P ＞ 0.05).After treatment,the ADL scores of the two groups were increased (t =5.673,8.223,all P ＜ 0.05).Meanwhile,the ADL score of the observation group was higher than that of the control group (t =2.920,P ＜ 0.05).Conclusion The application of progressively controlled decompression combined with hyperbaric oxygen in patients with emergency craniocerebral trauma is conductive to reduce acute encephalocele,bone window brain tissue incarceration,delayed hematoma,postoperative cerebral infarction and other complications.Besides,it can repair the damaged nerve cells,and eventually improve activities of daily living of patients and reduce morbidity and mortality,and the prognosis is better.