Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II
Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe head injury patients showing lesions type I-II in the initial CT scan
R.D. Lobato
, J.F. Alen, A. Perez-Nuñez, R. Alday, P.A. Gómez, B. Pascual, A. Lagares, P. Miranda, I. Arrese, A. Kaen
Servicio de Neurocirugía. Hospital 12 de Octubre, Madrid
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"apellidos" => "Lobato" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.F." "apellidos" => "Alen" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Perez-Nuñez" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Alday" ] 4 => array:2 [ "nombre" => "P.A." "apellidos" => "Gómez" ] 5 => array:2 [ "nombre" => "B." "apellidos" => "Pascual" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Lagares" ] 7 => array:2 [ "nombre" => "P." "apellidos" => "Miranda" ] 8 => array:2 [ "nombre" => "I." "apellidos" => "Arrese" ] 9 => array:2 [ "nombre" => "A." "apellidos" => "Kaen" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Neurocirugía. Hospital 12 de Octubre, Madrid" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Correspondencia postal: Servicio Neurocirugía. Hospital “12 de Octubre”. Avda Córdoba/sn. 28041 Madrid." ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe head injury patients showing lesions type I-II in the initial CT scan" ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2004-09-10" "fechaAceptado" => "2004-11-11" "PalabrasClave" => array:2 [ "es" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec158874" "palabras" => array:7 [ 0 => "Trauma craneal" 1 => "Coma" 2 => "Contusión cerebral" 3 => "Hematoma epidural" 4 => "Lesión axonal difusa" 5 => "Tomografía computarizada" 6 => "Presión intracraneal" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abreviaturas" "identificador" => "xpalclavsec158876" "palabras" => array:9 [ 0 => "ECG" 1 => "HIC" 2 => "HIV" 3 => "HSA" 4 => "PIC" 5 => "TAC" 6 => "TCDB" 7 => "TCG" 8 => "TTPA" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Key words" "identificador" => "xpalclavsec158875" "palabras" => array:6 [ 0 => "head injury" 1 => "Postraumatic coma" 2 => "Brain contusión epidural hematoma" 3 => "Axonal injury" 4 => "Computerized tomography" 5 => "Intracranial pressure" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar los cambios en la patología y presión intracraneal (PIC) durante el periodo agudo postraumático en una serie de pacientes con trauma craneal grave y lesiones Tipos I-II en la TAC inicial (clasificación del Traumatic Coma Data Bank) con el objetivo de diseñar la pauta mas adecuada de uso de TAC secuencial y monitorización de la PIC para detectar nuevo efecto masa intracraneal y tratar así de mejorar la evolución final de pacientes.</p> <span class="elsevierStyleSectionTitle">Material y métodos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se analiza una serie de 56 pacientes (edades = 15–80 años) admitidos consecutivamente en un periodo de dos años que fueron sometidos a TAC inicial < 24 horas tras el impacto, (intervalo medio = 150 minutos), TACs control en los primeros días del curso, y monitorización de la PIC. Se recogieron diferentes variables epidemiológicas, clínicas, radiológicas y se consideró como variable dependiente el desarrollo de deterioro definido como elevación mantenida de la PIC por encima de 20<span class="elsevierStyleHsp" style=""></span>mmHg que requiriera tratamiento agresivo médico y/o quirúrgico. Mediante análisis bi y multivariante se determinaron las correlaciones entre las diferentes variables y la aparición de deterioro. Para estimar la afectación neurológica y el resultado final se emplearon las escalas de coma y evolución de Glasgow, respectivamente.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El “score” medio en la serie fue de 5, y 37% de los pacientes tuvieron cambios pupilares, 52,3% hipotensión-hipoxemia, 16.1% anemia peritraumáticas y 12,3% alteraciones de la coagulación. 50% de los pacientes mostraron petequias en sustancia blanca y/o tronco cerebral en la TAC inicial, 66% HSA, 40% HIV, 39,3% contusión y 21,4% hematomas extraaxiales. 57,1% de los pacientes mostraron cambios en la TAC de control consistentes en nueva contusión en 26,8% de los casos, crecimiento de contusión previa en 68,2%, crecimiento de hematoma previo en 10,7% y swelling cerebral generalizado en 10,7%. 64% de los pacientes experimentaron una evolución final favorable y 35,7% desfavorable.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">27 pacientes (48,9%) desarrollaron deterioro PIC, de los que 21 (37,5%) presentaron cambios concurrentes en la TAC, y 6 (10,7%) no los mostraron. Los restantes 29 (51,7%) pacientes no presentaron deterioro PIC, aunque 11 (19,6%) de ellos mostraron cambio TAC. La edad, el “score”, la presencia de hipotension-hipoxemia peritraumáticas y los trastornos de la coagulación no se correlacionaron con riesgo de deterioro. Por el contrario, la presencia de contusión inicial (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,01) y el cambio TAC (en forma de desarrollo de swelling cerebral generalizado, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,003) se correlacionaron con la aparición de deterioro; a su vez el deterioro multiplicó por 10 (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>9,8) el riesgo de muerte y 7 de los 8 pacientes que fallecieron desarrollaron hipertensión intracraneal intratable. Los 8 pacientes (14,2%) que necesitaron cirugía evacuadora o descompresiva presentaron simultáneamente cambio PIC y cambio TAC, si bien otros 13 en situación similar pudieron ser manejados sin cirugía. Mostraran o no deterioro PIC, los pacientes sin cambio TAC evolucionaron mejor que los que desarrollaron nuevas patologías, pero la diferencia no alcanzó diferencia significativa.</p> <span class="elsevierStyleSectionTitle">Discusión y conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Más de la mitad de los pacientes con lesión inicial Tipo I-II desarrolla cambios patológicos secuenciales, y casi el 50% presenta hipertensión intracraneal. Dada la alta incidencia de cambios TAC y PIC, la escasez y debilidad de los factores predictores de dichos cambios, y la frecuente discordancia entre ambos tipos de cambio (30,3% de los casos), parece recomendable monitorizar la PIC desde el inicio y practicar TACs 2–4,12, 24, 48 y 72 horas tras el impacto en todos los pacientes, y otros adicionales si la evolución clínica o de la PIC lo requiriera.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Si bien parece indudable que el desarrollo de hipertensión intracraneal grave incrementó significativamente el riesgo de muerte, la escasez de la muestra en la serie no permite determinar la contribución del nuevo efecto masa y/o la elevación de la PIC al desarrollo de incapacidad moderada y grave en los pacientes que no fallecieron, causada principalmente por la lesión axonal difusa. Finalmente, demostrar que la practica de TAC secuencial y la monitorizacion de la PIC mejoran la evolución final de este tipo de pacientes requeriría un estudio prospectivo aleatorizado que no es practicable por diferentes razones, entre ellas las de tipo ético.</p>" ] "en" => array:2 [ "titulo" => "Summary" "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">. To determine the incidence of pathological and intracranial pressure (ICP) changes during the acute posttraumatic period in severe head injury patients presenting with lesions Types I-II (TCDB classification) in the admission CT sean with the aim of defining the most appropriate strategy of sequential CT scanning and ICP monitoring for detecting new intracranial mass effect and improving the final outeome.</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">. 56 patients (ages 15–80 years) consecutively admitted during a 2 years period were included. All had the initial CT sean < 24 hours after injury (mean interval = 150<span class="elsevierStyleHsp" style=""></span>min), several CT controls within the first days of the course and ICP monitoring after admission. Different epidemiological, clinical and radiological variables were recorded and deterioration defined as the development of sustained ICP over 20<span class="elsevierStyleHsp" style=""></span>mmHg requiring aggressive medical and/or surgical treatment was considered the dependent variable. Uni and multivariate analyses were made for determining the correlation between different parameters and the oceurrence of deterioration and the final outeome as assessed with the GOS.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">. The mean GCS score was 5 and 37% of the patients showed pupillary changes; 52.3% had peritraumatic hypotension-hypoxemia, 16.1% anemia and 12.3% coagulation changes. 50% of the patients showed petechial hemorrhages in the white matter or the brainstem, 66% SAH, 40% HIV, 39.3% brain contusión and 21.4% small extraxial hematomas. 57.1% of the patients showed CT changes through the acute posttraumatic period consisting of new contusión (26.8% of the cases), growing of previous contusión (68.2%) or previous extraaxial hematoma (10.7%), and generalized brain swelling (10.7%). 64.9% of the patients made a favourable and 35.7% an unfavourable outcome.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Overall, 27 (48.9%) patients developed deterioration, 21 (37.5%) with concurrent CT changes and 6 (10,7%) without new pathology as seen by the CT control. The remaining 29 (51.7%) patients in this series did not develop deterioration in spite that 11(19.6%) showed CT changes. The age, the initial score, the oceurrence of peritraumatic hypotension-hypoxemia and coagulation disorders did not correlate with the risk of deterioration. By contrast, the presence of contusión at the initial CT sean (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.01) and the oceurrence of CT change (only generalized brain swelling, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.003) significantly correlated with the risk of deterioration; in his turn deterioration increased by a factor of 10 (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>9,8) the risk of death and 7 out of the 8 patients who died developed intractable intracranial hypertension. The 8 (14.2%) patients requiring surgery showed simultaneous ICP deterioration and CT changes, but another 11 patients in a similar condition could be managed without surgery. With or without ICP deterioration, patients showing CT changes had a worse outeome than those without new pathologies, but the difference did not reach statistical significance,</p> <span class="elsevierStyleSectionTitle">Discussion and conclusions</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">. Over 50% of the patients with initial Type I-II lesions developed new CT changes and nearly 50% showed intracranial hypertension during the acute posttraumatic period. Considering the high incidences of ICP and CT deterioration through the course, along with the absence of strong predictors and the discordances between CT and ICP changes (which were seen in 30.3% of the cases) we recommend ICP monitoring after admission in all patients and serial CT scanning at 2–4,12, 24, 48 and 72 hours after injury with additional controls as indicated by clinical or ICP changes in all cases.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Though it is clear that the presence of severe intracranial hypertension significantly increased the risk of death, the small size of the sample in this series prevented to assess to what extent the oceurrence of new mass effect and/or raised ICP contributed to the development of modérate and severe disability in the survivors which were mainly due to the oceurrence of diffuse axonal injury. Finally, demonstrating that sequential CT scanning and ICP monitoring improve the final outeome in this type of patients would require a prospective randomized trial which is impracticable for different reasons, among them the ethical ones.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Lobato, R.D.; Alen, J.F.; Perez-Nuñez, A.; Alday, R.; Gómez, P.A.; Pascual, B.; Lagares, A.; Miranda, P.; Arrese, L; Kaen, A.: Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II. Neurocirugía 2005; 16: 217–234.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1." 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Mayo | 1 | 0 | 1 |
| 2023 Marzo | 5 | 2 | 7 |
| 2018 Octubre | 0 | 5 | 5 |
| 2018 Marzo | 5 | 4 | 9 |
| 2018 Febrero | 15 | 9 | 24 |
| 2018 Enero | 43 | 13 | 56 |
| 2017 Diciembre | 17 | 8 | 25 |
| 2017 Noviembre | 25 | 13 | 38 |
| 2017 Octubre | 20 | 15 | 35 |
| 2017 Septiembre | 27 | 19 | 46 |
| 2017 Agosto | 20 | 23 | 43 |
| 2017 Julio | 21 | 16 | 37 |
| 2017 Junio | 28 | 21 | 49 |
| 2017 Mayo | 26 | 22 | 48 |
| 2017 Abril | 21 | 17 | 38 |
| 2017 Marzo | 17 | 18 | 35 |
| 2017 Febrero | 17 | 6 | 23 |
| 2017 Enero | 18 | 16 | 34 |
| 2016 Diciembre | 28 | 13 | 41 |
| 2016 Noviembre | 33 | 14 | 47 |
| 2016 Octubre | 32 | 15 | 47 |
| 2016 Septiembre | 44 | 11 | 55 |
| 2016 Agosto | 28 | 10 | 38 |
| 2016 Julio | 26 | 20 | 46 |
| 2016 Junio | 1 | 0 | 1 |
| 2016 Marzo | 8 | 0 | 8 |
| 2016 Febrero | 1 | 0 | 1 |
| 2015 Diciembre | 2 | 0 | 2 |
| 2015 Octubre | 1 | 0 | 1 |
| 2015 Septiembre | 1 | 0 | 1 |
| 2015 Julio | 2 | 0 | 2 |
| 2015 Junio | 11 | 4 | 15 |
| 2015 Mayo | 22 | 10 | 32 |
| 2015 Abril | 19 | 12 | 31 |
| 2015 Marzo | 15 | 15 | 30 |
| 2015 Febrero | 13 | 13 | 26 |
| 2015 Enero | 11 | 15 | 26 |
| 2014 Diciembre | 18 | 15 | 33 |
| 2014 Noviembre | 16 | 7 | 23 |
| 2014 Octubre | 22 | 17 | 39 |
| 2014 Septiembre | 22 | 15 | 37 |
| 2014 Agosto | 17 | 12 | 29 |
| 2014 Julio | 18 | 17 | 35 |
| 2014 Junio | 22 | 17 | 39 |
| 2014 Mayo | 29 | 20 | 49 |
| 2014 Abril | 25 | 13 | 38 |
| 2014 Marzo | 27 | 15 | 42 |
| 2014 Febrero | 19 | 21 | 40 |
| 2014 Enero | 19 | 17 | 36 |
| 2013 Diciembre | 22 | 15 | 37 |
| 2013 Noviembre | 19 | 18 | 37 |
| 2013 Octubre | 17 | 24 | 41 |
| 2013 Septiembre | 29 | 31 | 60 |
| 2013 Agosto | 39 | 32 | 71 |
| 2013 Julio | 36 | 26 | 62 |
| 2013 Junio | 23 | 33 | 56 |
| 2013 Mayo | 15 | 36 | 51 |
| 2013 Abril | 23 | 33 | 56 |
| 2013 Marzo | 21 | 40 | 61 |
| 2013 Febrero | 13 | 20 | 33 |
| 2013 Enero | 14 | 25 | 39 |
| 2012 Diciembre | 8 | 32 | 40 |
| 2012 Noviembre | 1 | 8 | 9 |
| 2012 Octubre | 0 | 1 | 1 |
| 2012 Septiembre | 0 | 1 | 1 |
| 2012 Enero | 17 | 0 | 17 |
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