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Mortalidad a los 30 das en pacientes con TCE sometidos a Craniectoma Descompresiva

Dr. Gustavo Gonzlez. Residente Primer Ao, Neurociruga

Introduccin.

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Introduccin
Edema Cerebral Maligno

Hipertensin Endocraneana
Craniectoma Descompresiva
Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Introduccin

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Introduccin

TCE
30 das

Muerte

Craniectoma Descompresiva

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Introduccin
Determinar la incidencia y las causas de las muertes. Identificar los factores de riesgo.

Objetivo

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Metodologa
Kaohsiung Chang Gung Memorial Hospital, Taiwn.

201 pacientes
Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Metodologa
Se establecieron perodos de tiempo.

Se identificaron causas de muerte

Se recolectaron datos demogrficos

Se recolectaron datos clnicos


Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Metodologa
Indicaciones para Craniectoma Descompresiva
Evacuacin de lesin intradural y disminucin de la elevada presin intracraneal refractaria a tratamiento mdico.

Metodologa
Craniectoma Primaria
Descompresin quirrgica con o sin exresis de parnquima cerebral, en primer lugar para la evacuacin de una lesin intradural

Craniectoma Secundaria

Pacientes con PIC mayor a 25mmHg refractaria a tratamiento mdico (cabecera, manitol, temp, sedoanalgesia, hiperventilacin) Pacientes con ciruga intracraneal previa

Metodologa
Craniectoma unilateral/ bilateral
Apertura de la duramadre Cubierta del parnquima Monitoreo de PIC en algunos casos

Metodologa

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Metodologa
Estadsticas presentadas como frecuencias o medias con DE
Para evaluar los factores de riesgo se utiliz el Sistema de regresin logstico

Resultados expresados en Odds Ratio


Se tomaron en cuenta valores con p menor a 0,05 Se estudi la supervivencia con las tablas de KaplanMeier.
Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Resultados

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Resultados

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Resultados

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Resultados

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Resultados

Fig. 1. Distributions of time to mortality. Group A includes patients with brain swelling and brain infarction; Group B, those with delayed intraaxial and extraaxial hemorrhage; and Group C, those with medical morbidity-related deaths. Error bars show 95% CIs.
Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Resultados

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Resultados
Fig. 2. Kaplan-Meier survival curves for traumatically brain-injured patients undergoing decompressive craniectomy according to age group (p = 0.028, logrank test).

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing

Resultados
Fig. 3. Kaplan-Meier survival curves for traumatically brain-injured patients undergoing decompressive craniectomy according to GCS group ( p < 0.001, log-rank test).

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing

Discusin
2004 Brown y colab: 29% mortalidad en TCE moderado y severo en 30 das.

2008 Myburgh y colab. 32% mortalidad en TCE severo a los 4 meses.


Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Discusin

Aarabi y colab. 2006


22,4%

Yu-Hua y colab. 2013


26,4%

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Discusin
Edema cerebral e infarto fueron las principales causas irreversibles de muerte. En contraparte, las hemorragias postoperatorias fueron menos comunes en los pacientes estudiados.

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing

Discusin
Aarabi y colab analizaron 6 predictores de muerte en los primeros 30 das:
Edad

Glasgow inicial
Respuesta motora del Glasgow Respuesta pupilar anormal Desviacin de lnea media
Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Discusin
Yu-Hua y colab.

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Discusin
Cambios alrededor de los 40 aos. Buena supervivencia en mayores de 65 aos No debe tomarse en cuenta de forma aislada.

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Discusin
La seleccin de pacientes segn su estado neurolgico disminuye la mortalidad posterior a la ciruga
Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Discusin

Limitaciones del estudio


La informacin puede estar incompleta e en registro Glasgow segn observador Solo se Muestra reflejan relativamente resultados de pequea un hospital

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.

Conclusiones
Existe una alta tasa de mortalidad en los primeros 30 das posterior a craniectoma descompresiva en el TCE.

Los factores de riesgo involucrados con la mortalidad son la edad y el puntaje de Glasgow antes de la ciruga.

Y. H. Huang et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J Neurosurg / March 8, 2013.