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Life
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Trauma and Emergency: Beyond Damage Control Surgery
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Trauma and Emergency: Beyond Damage Control Surgery

A special issue of Life (ISSN 2075-1729). This special issue belongs to the section "Medical Research".

Deadline for manuscript submissions: closed (31 December 2021) | Viewed by 25432

Special Issue Editors

Dr. Giuseppe Ietto

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Guest Editor
Emergency and Transplant Surgery Department, University of Insubria, 21100 Varese, Italy
Interests: kidney transplantation; surgery transplantation; dialysis; oncology; immunology
Special Issues, Collections and Topics in MDPI journals
Dr. Gabriele Soldini

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Guest Editor
Ospedale Sacra Famiglia, Ordine Ospedaliero di San Giovanni di Dio Fatebenefratelli - Erba (Como), Italy
Dr. Francesco Amico

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Guest Editor
Trauma Service, Department of Surgery, University of Newcastle – Newcastle, Australia
Dr. Caterina Franchi

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Guest Editor
Resident surgeon at General, Emergency and Transplant Surgery Department-ASST dei Sette Laghi, via Guicciardini 9, 21100 Varese, Italy
Interests: trauma and emergency surgery; robotic surgery; visceral surgery; transplant surgery; thyroid surgery
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,


Following major trauma, outcomes correlates with both appropriateness and timeliness of diagnosis and treatment but, first and foremost, with severity of injury.
In fact, a severe trauma almost instantaneously leads to a high level of cell death with the release of debris cell’s fragments. These DAMPs (damage-associated molecular patterns) sustain the following cascade and the pathophysiological consequences, structured in the mechanistic insight depicted in the so-called “Danger model”.
The “Danger model”, the paradigm described in 2002 by Matzinger, suggests that damage’s products and alarm signals from injured tissues are the main ones responsible for the activation of the immune system.
The extremely varying range of severity of sterile post-injury inflammation and its consequent inauspicious organ dysfunctions seems to correlate with the level of immune reaction, consistent with the degree of the initial tissue damage caused by the trauma.
mt-DNA is one of the most frequently investigated and probably one of the best described DAMPs, both a marker and instigator of sterile post-injury inflammation. It spreads after cell necrosis and by an active process when even intact functioning mitochondria can leak out of stressed cells responding to major trauma. Mitochondria and their products can turn into an enemy within the body, akin to a “Trojan horse”.
In addition to danger molecules, neutrophil-associated extracellular trap (NET) formation also plays an emerging role in sustaining inflammatory response.
First described by Brinkmann and colleagues, NETosis is a cell death pathway distinct from apoptosis and necrosis; it faces neutrophils, entering tissues and organs following an injury and forming neutrophil extracellular traps (NETs).
Although NETs play an important role in host defence by trapping pathogens, extensive formation of NETs with increased amounts of extracellular DNA may contribute to the spread of inflammation and tissue damage. Recent reports indicate that NETs may contribute to tissue damage and organ dysfunction.
A deep knowledge of these pathomechanisms might be extremely interesting in both predicting the outcome and defining the most therapeutically suitable approach after severe trauma.
We are extremely excited to explore all the new findings concerning this field in terms of pathophysiological knowledge, diagnostic and prognostic approaches, and therapeutic strategies.

Dr. Giuseppe Ietto
Dr. Gabriele Soldini
Dr. Francesco Amico
Dr. Caterina Franchi
Guest Editors

Manuscript Submission Information

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Keywords

  • Major trauma
  • DAMPs (damage-associated molecular patterns)
  • NETs (neutrophil extracellular traps)
  • SIRS (systemic inflammatory response syndrome)
  • MODS (multiple organ dysfunction syndrome)
  • DCS (damage control surgery)
  • PICS (persistent inflammation, immunosuppression, and catabolism syndrome)

Published Papers (10 papers)

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Editorial

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4 pages, 179 KiB  
Editorial
Beyond the Trauma Triad of Death—New Advances in Our Knowledge of Pathophysiology as a Basis for New Perspectives in Support Therapy
by Giuseppe Ietto, Caterina Franchi, Gabriele Soldini and Francesco Amico
Life 2022, 12(3), 428; https://doi.org/10.3390/life12030428 - 16 Mar 2022
Viewed by 2041
Abstract
The history of staged laparotomy, the basic idea behind the so called “Damage Control Surgery (DCS)” attitude, leans on the experience developed during the treatment of major hepatic trauma that was sustained by Pringle’s pioneering attempts to achieve hemostasis on liver wounds via [...] Read more.
The history of staged laparotomy, the basic idea behind the so called “Damage Control Surgery (DCS)” attitude, leans on the experience developed during the treatment of major hepatic trauma that was sustained by Pringle’s pioneering attempts to achieve hemostasis on liver wounds via packing in 1908 [...] Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)

Research

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8 pages, 208 KiB  
Article
Organ Donation after Damage Control Strategy in Trauma Patients: Experience from First Level Trauma Center in Italy
by Michele Altomare, Shir Sara Bekhor, Stefano Piero Bernardo Cioffi, Marco Sacchi, Federica Renzi, Andrea Spota, Roberto Bini, Federico Ambrogi, Federico Pozzi, Arturo Chieregato, Osvaldo Chiara and Stefania Cimbanassi
Life 2022, 12(2), 214; https://doi.org/10.3390/life12020214 - 30 Jan 2022
Cited by 3 | Viewed by 1752
Abstract
Background: Organ donation (OD) remains the only therapeutic option for end-stage disease in some cases. Unfortunately, the gap between donors and recipients is still substantial. Trauma patients represent a potential yet underestimated pool of organ donors. In this article, we present our data [...] Read more.
Background: Organ donation (OD) remains the only therapeutic option for end-stage disease in some cases. Unfortunately, the gap between donors and recipients is still substantial. Trauma patients represent a potential yet underestimated pool of organ donors. In this article, we present our data on OD after damage control strategy (DCS). Materials and Methods: A retrospective, observational cohort study was conducted through a complete revision of data of consecutive adult trauma patients (>18 years old) who underwent OD after DCS between January 2018 and May 2021. Four subgroups were created [Liver (Li), Lungs (Lu), Heart (H), Kidneys (K)] to compare variables between those who donated the organ of interest and those who did not. Results: Thirty-six patients underwent OD after DCS. Six patients (16.7%) were excluded: 2(5.6%) for missing data about admission; 4(11.1%) didn’t receive DCS. Mean ISS was 47.2 (SD ± 17.4). Number of donated organs was 113 with an organs/patient ratio of 3.8. The functional response rate was 91.2%. Ten organs (8.8%) had primary nonfunction after transplantation: 2/15 hearts (13.3%), 1/28 livers (3.6%), 4/53 kidneys (7.5%) and 3/5 pancreases (60%). No lung primary nonfunction were registered. Complete results of subgroup analysis are reported in supplementary materials. Conclusion: Organ donation should be considered a possible outcome in any trauma patient. Aggressive damage control strategy doesn’t affect the functional response rate of transplanted organs. Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)
14 pages, 2558 KiB  
Article
Systematic Review and Meta-Analysis of Wound Bundles in Emergency Midline Laparotomy Identifies That It Is Time for Improvement
by Gearóid Mc Geehan, Itoro M. Edelduok, Magda Bucholc, Angus Watson, Zsolt Bodnar, Alison Johnston and Michael Sugrue
Life 2021, 11(2), 138; https://doi.org/10.3390/life11020138 - 11 Feb 2021
Cited by 7 | Viewed by 2814
Abstract
Background: Emergency midline laparotomy is the cornerstone of survival in patients with peritonitis. While bundling of care elements has been shown to optimize outcomes, this has focused on elective rather than emergency abdominal surgery. The aim of this study was to undertake a [...] Read more.
Background: Emergency midline laparotomy is the cornerstone of survival in patients with peritonitis. While bundling of care elements has been shown to optimize outcomes, this has focused on elective rather than emergency abdominal surgery. The aim of this study was to undertake a systematic review and meta-analysis of factors affecting the development of surgical site infection (SSI) in patients undergoing midline emergency laparotomy. Methods: An ethically approved, PROSPERO registered (ID: CRD42020193246) meta-analysis and systematic review, searching PubMed, Scopus, Web of Science and Cochrane Library electronic databases from January 2015 to June 2020 and adhering to PRISMA guidelines was undertaken. Search headings included “emergency surgery”, “laparotomy”, “surgical site infection”, “midline incision” and “wound bundle”. Suitable publications were graded using Methodological Index for Non-Randomised Studies (MINORS); papers scoring ≥16/24 were included for data analysis. The primary outcome in this study was SSI rates following the use of wound bundles. Secondary outcomes consisted of the effect of the individual interventions included in the bundles and the SSI rates for superficial and deep infections. Five studies focusing on closure techniques were grouped to assess their effect on SSI. Results: This study identified 1875 articles. A total of 58 were potentially suitable, and 11 were included after applying MINORS score. The final cohort included 2,856 patients from eight countries. Three papers came from the USA, two papers from Japan and the remainder from Denmark, England, Iran, Netherlands, Spain and Turkey. There was a 32% non-significant SSI reduction after the implementation of wound bundles (RR = 0.68; CI, 0.39–1.17; p = 0.16). In bundles used for technical closure the reduction in SSI of 15% was non-significant (RR = 0.85; CI, 0.57–1.26; p = 0.41). Analysis of an effective wound bundle was limited due to insufficient data. Conclusions: This study identified a significant deficit in the world literature relating to emergency laparotomy and wound outcome optimisation. Given the global burden of emergency general surgery urgent action is needed to assess bundle’s ability to potentially improve outcome after emergency laparotomy. Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)
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11 pages, 542 KiB  
Article
Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care
by Syed Mohammad Umar Kabir, Magda Bucholc, Carol-Ann Walker, Opeyemi O. Sogaolu, Saqib Zeeshan and Michael Sugrue
Life 2020, 10(12), 358; https://doi.org/10.3390/life10120358 - 18 Dec 2020
Cited by 5 | Viewed by 3222
Abstract
Introduction: Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy [...] Read more.
Introduction: Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy and outcomes. Methods: An ethically approved retrospective cohort study was undertaken between March 2016 and March 2017 at a single university hospital of all consecutive adult and paediatric patients undergoing appendectomy. Demographic data including age, gender, co-morbidities, presentation and triage timings along with investigation, imaging and operative data were analysed. Appendicitis was defined as acute based on histology coupled with intraoperative grading with the American Association for the Surgery of Trauma (AAST) grades. Complications using the Clavien–Dindo classification along with 30-day re-admission rates and the negative appendectomy rates (NAR) were recorded and categorised greater and less than 25%. The use of scoring systems was assessed, and retrospective scoring performed to compare the Alvarado, Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score. Results: A total of 201 patients were studied, 115 male and 86 females, of which 136/201 (67.6%) were adults and 65/201 (32.3%) paediatric. Of the adult group, 83 were male and 53 were female, and of the paediatric group, 32 were male and 33 were female. Median age was 20 years (range: 5 years to 81 years) and no patient below the age of 5 years had an appendectomy during our study period. All patients were admitted via the emergency department and median time from triage to surgical review was 2 h and 38 min, (range: 10 min to 26 h and 10 min). Median time from emergency department review to surgical review, 55 min (range: 5 min to 6 h and 43 min). Median time to operating theatre was 21 h from admission (range: 45 min to 140 h and 30 min). Out of the total patients, 173 (86.1%) underwent laparoscopic approach, 28 (13.9%) had an open approach and 12 (6.9%) of the 173 were converted to open. Acute appendicitis occurred in 166/201 (82.6%). There was no significant association between grade of appendicitis and surgeons’ categorical NAR rate (p = 0.07). Imaging was performed in 118/201 (58.7%); abdominal ultrasound (US) in 53 (26.4%), abdominal computed tomography (CT) in 59 (29.2%) and both US and CT in 6 (3%). The best cut-off point was 4 (sensitivity 84.3% and specificity of 65.7%) for AIR score, 9 (sensitivity of 74.7% and specificity of 68.6%) for AAS, and 7 (sensitivity of 77.7% and specificity of 71.4%) for the Alvarado score. Twenty-four (11.9%) were re-admitted, due to pain in 16 (58.3%), collections in 3 (25%), 1 (4.2%) wound abscess, 1 (4.2%) stump appendicitis, 1 (4.2%) small bowel obstruction and 1 (4.2%) fresh rectal bleeding. CT guided drainage was performed in 2 (8.3%). One patient had release of wound collection under general anaesthetic whereas another patient had laparoscopic drain placement. A laparotomy was undertaken in 3 (12.5%) patients with division of adhesions in 1, the appendicular stump removed in 1 and 1 had multiple collections drained. Conclusion: The negative appendectomy and re-admission rates were unacceptably high and need to be reduced. Minimising surgical variance with use of scoring systems and introduction of pathways may be a strategy to reduce NAR. New systems of feedback need to be introduced to improve outcomes. Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)
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Review

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13 pages, 328 KiB  
Review
Liver Trauma: Until When We Have to Delay Surgery? A Review
by Inés Cañas García, Julio Santoyo Villalba, Domenico Iovino, Caterina Franchi, Valentina Iori, Giuseppe Pettinato, Davide Inversini, Francesco Amico and Giuseppe Ietto
Life 2022, 12(5), 694; https://doi.org/10.3390/life12050694 - 6 May 2022
Cited by 6 | Viewed by 3127
Abstract
Liver involvement after abdominal blunt trauma must be expected, and in up to 30% of cases, spleen, kidney, and pancreas injuries may coexist. Whenever hemodynamics conditions do not contraindicate the overcoming of the ancient dogma according to which exploratory laparotomy should be performed [...] Read more.
Liver involvement after abdominal blunt trauma must be expected, and in up to 30% of cases, spleen, kidney, and pancreas injuries may coexist. Whenever hemodynamics conditions do not contraindicate the overcoming of the ancient dogma according to which exploratory laparotomy should be performed after every major abdominal trauma, a CT scan has to clarify the liver lesions so as to determine the optimal management strategy. Except for complete vascular avulsion, no liver trauma grade precludes nonoperative management. Every attempt to treat the injured liver by avoiding a strong surgical approach may be considered. Each time, a nonoperative management (NOM) consisting of a basic “wait and see” attitude combined with systemic support and blood replacement are inadequate. Embolization should be considered to stop the bleeding. Percutaneous drainage of collections, endoscopic retrograde cholangiopancreatography (ERCP) with papilla sphincterotomy or stent placement and percutaneous transhepatic biliary drainage (PTBD) may avoid, or at least delay, surgical reconstruction or resection until systemic and hepatic inflammatory remodeling are resolved. The pathophysiological principle sustaining these leanings is based on the opportunity to limit the further release of cell debris fragments acting as damage-associated molecular patterns (DAMPs) and the following stress response associated with the consequent immune suppression after trauma. The main goal will be a faster recovery combined with limited cell death of the liver through the ischemic events that may directly follow the trauma, exacerbated by hemostatic procedures and surgery, in order to reduce the gross distortion of a regenerated liver. Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)
16 pages, 348 KiB  
Review
Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review
by Giuseppe Ietto, Francesco Amico, Giuseppe Pettinato, Valentina Iori and Giulio Carcano
Life 2021, 11(9), 917; https://doi.org/10.3390/life11090917 - 3 Sep 2021
Cited by 7 | Viewed by 3533
Abstract
A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, [...] Read more.
A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”. Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)
14 pages, 8186 KiB  
Review
Anterior Dural Tear in Thoracic and Lumbar Spinal Fractures: Single-Center Experience with Coating Technique and Literature Review of the Available Strategies
by Giorgio Lofrese, Jacopo Visani, Francesco Cultrera, Pasquale De Bonis, Luigino Tosatto and Alba Scerrati
Life 2021, 11(9), 875; https://doi.org/10.3390/life11090875 - 25 Aug 2021
Cited by 4 | Viewed by 2469
Abstract
Differently from the posterior, the anterior dural tears associated with spinal fractures are rarely reported and debated. We document our experience with a coating technique for repairing ventral dural lacerations, providing an associated literature review on the available strategies to seal off such [...] Read more.
Differently from the posterior, the anterior dural tears associated with spinal fractures are rarely reported and debated. We document our experience with a coating technique for repairing ventral dural lacerations, providing an associated literature review on the available strategies to seal off such dural defects. A PubMed search on watertight repair techniques of anterior dural lacerations focused on their association with spinal fractures was performed. Studies on animal or cadaveric models, on cervical spine, or based on seal/gelfoam or “not suturing” strategies were excluded. 10 studies were finally selected and our experience of three patients with thoracic/lumbar spinal fractures with associated ventral dural tear was integrated into the analysis of the surgical techniques. Among the described repair techniques for ventral dural lacerations a preference for primary suturing, mostly trans-dural, was noted (n = 6/10 papers). Other documented strategies were the plugging of the dural opening with a fat graft sutured to its margins, or stitched to the dura adjacent to the defect, and the closure of the dural tear with two patches, both trans-dural and epidural. Our coating techniques of the whole dural sac with the heterologous patch were revealed as safe and effective alternatives strategies, even when patch flaps wrapping nerve roots have to be cut and a fat graft has to be stitched in the patch respectively for sealing off antero-lateral and wide anterior dural tears. Compared to all the documented strategies for obtaining a watertight closure of an anterior dural laceration, the coating techniques revealed advantages of preserving neural structures, being adaptable to anterior and antero-lateral dural tears of any size. Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)
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Other

10 pages, 3689 KiB  
Case Report
Meckel’s Diverticulum Causing Ileal Volvulus and Peritonitis after a Recent Appendectomy: A Case Report and Literature Review—We Should Likely Resect an Incidental MD
by Matteo Zanchetta, Davide Inversini, Vincenzo Pappalardo, Niccolo Grappolini, Marika Morabito, Simone Gianazza, Giulio Carcano and Giuseppe Ietto
Life 2023, 13(10), 1996; https://doi.org/10.3390/life13101996 - 30 Sep 2023
Cited by 1 | Viewed by 920
Abstract
Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract with a 1–3% prevalence in the general population. The surgical management of symptomatic MD is well described in the literature, but there is still no consensus on the indication for [...] Read more.
Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract with a 1–3% prevalence in the general population. The surgical management of symptomatic MD is well described in the literature, but there is still no consensus on the indication for prophylactic resection of incidental asymptomatic MD. To address this issue, we extensively reviewed the current literature and report our experience with laparoscopic management of an unusual case of MD causing ileal volvulus and acute peritonitis two weeks after a laparoscopic appendectomy for acute gangrenous appendicitis performed in another hospital. A 50-year-old man presented to the emergency department with acute and severe abdominal pain, vomiting, and constipation. He had undergone a laparoscopic appendectomy for acute appendicitis two weeks before in another hospital. The patient was apyretic, distressed, and seeking an antalgic position. The abdomen was mildly distended and tender, and the Blumberg sign was mildly positive in the central quadrants. The clinical picture deteriorated with fever, peritonismus, and leukocytosis. A CT scan showed an ileo–ileal adhesion near the ileocolic junction and dilatation of the upstream loops with the air–fluid levels. Through an urgent laparoscopy, a necrotic mass, the MD, was wedge-resected, and the surrounding ileal volvulus derotated. The postoperative course was uneventful. There is no definitive consensus on the appropriate management of incidental asymptomatic MD, although several studies have attempted to identify guiding criteria. Features of the MD, the patient’s risk factors, clinical presentation, and surgical approach need to be considered to establish definitive guidelines for the management of incidental asymptomatic MD. In the absence of definitive guidelines, personal expertise and judgement are the main resources for the surgeon approaching an incidental asymptomatic MD. Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)
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11 pages, 8087 KiB  
Case Report
Dental Prosthesis in Esophagus: A Right Cervicotomic Approach
by Matteo Zanchetta, Elisa Monti, Lorenzo Latham, Jessica Costa, Alessandro Marzorati, Murad Odeh, Elisabetta Marta Colombo, Giuseppe Ietto, Davide Inversini, Domenico Iovino, Marco Paolo Maffioli, Luigi Fiorenzo Festi and Giulio Carcano
Life 2022, 12(8), 1170; https://doi.org/10.3390/life12081170 - 31 Jul 2022
Viewed by 1450
Abstract
Foreign body ingestion in the upper digestive tract is a relatively common emergency. Less than 1% have to be treated surgically. We report the case of a 68-year-old man who ingested a dental prosthesis, probably during a seizure, and thus unknowingly, and presented [...] Read more.
Foreign body ingestion in the upper digestive tract is a relatively common emergency. Less than 1% have to be treated surgically. We report the case of a 68-year-old man who ingested a dental prosthesis, probably during a seizure, and thus unknowingly, and presented two days later to the emergency department complaining of a mild dysphagia. A chest radiograph showed the presence of a removable dental prosthesis in the upper esophageal tract. The patient was brought to the operating room where a multidisciplinary equipe was assembled. Two attempts of retrieval with a flexible and a rigid endoscope failed because the removable dental prosthesis was stuck in the right pyriform sinus. Therefore, the surgeon performed an uncommon right cervicotomy and retrieved the foreign body through a right-side esophagotomy. The surgical approach depends on the nature and location of the foreign body. Urgent treatment is required whenever the patient develops dyspnea or dysphagia because of the high risk of inhalation and asphyxia. Removal of any esophageal foreign body has to be performed within 12–24 h. Repeated attempts to retrieve large dental prosthesis using an endoscope may result in esophageal perforation therefore when such risk of complication is too high, a surgical approach becomes inevitable. In our opinion, surgery remains the extrema ratio after a failed endoscopic retrieval attempt but can be lifesaving despite high risk of complications. Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)
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11 pages, 1239 KiB  
Case Report
Treating Spontaneous Intracranial Hypotension with an Anesthetic Modality: The Role of the Epidural Blood Patch
by Zoi Masourou, Nikolaos Papagiannakis, Georgios Mantzikopoulos, Dimos-Dimitrios Mitsikostas and Kassiani Theodoraki
Life 2022, 12(8), 1109; https://doi.org/10.3390/life12081109 - 23 Jul 2022
Cited by 4 | Viewed by 2306
Abstract
Background: Spontaneous intracranial hypotension (SIH) is a rare syndrome characterized by heterogeneity of presentation and prognosis, which can occasionally result in serious complications, such as the formation of subdural hematomas (SDHs). This case series aims to emphasize that SIH remains a diagnostic [...] Read more.
Background: Spontaneous intracranial hypotension (SIH) is a rare syndrome characterized by heterogeneity of presentation and prognosis, which can occasionally result in serious complications, such as the formation of subdural hematomas (SDHs). This case series aims to emphasize that SIH remains a diagnostic and therapeutic challenge; it can present with a broad clinical spectrum of symptoms, can lead to SDH and, if conservative treatment fails, an epidural blood patch (EBP) is a viable treatment option. Although the exact etiology of SIH is not known, it is believed to be due to cerebrospinal fluid (CSF) leak or a low CSF pressure. Case Series: Three patients (two males and one female) with ages ranging between 38 and 53 years old who presented with complaints of not only an orthostatic headache, but also a variety of symptoms of SIH, including the formation of two SDHs in one of them, were included in this series. These patients did not respond to conservative management and, subsequently, given the clinical and radiological evidence of SIH, were referred to the Anesthesiology Department for an EBP. Diagnostic workup was facilitated by imaging modalities, including magnetic resonance imaging (MRI) of the brain and spinal cord, prior to the EBP. All three patients were subjected to an EBP with an 18-gauge epidural needle. A total of between 30 and 43 mL of autologous blood was collected from the patients and was injected into the epidural space under strict aseptic conditions. Two lumbar (L1–L2, L2–L3) EBPs and one thoracic (T11–T12) EBP were performed on the three patients, respectively. All patients reported complete resolution of symptoms following the EBPs, while MRI improved substantially. Conclusions: This report describes three cases of SIH with CSF leak originating from the cervical, the thoracic and the lumbar level. The EBP restored CSF pressure and relieved the patients’ persistent symptoms. MRI helps in revealing indirect signs of a low volume of CSF, though it may not be possible to locate the actual site of the leak. In conclusion, EBP is a well-accepted and beneficial treatment modality for SIH when conventional measures fail. Full article
(This article belongs to the Special Issue Trauma and Emergency: Beyond Damage Control Surgery)
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