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Patel PP, Egodage T, Martin MJ. Decompressive craniectomy for traumatic brain injury: a review of recent landmark trials. Trauma Surg Acute Care Open 2025; 10:e001784. [PMID: 40260232 PMCID: PMC12010345 DOI: 10.1136/tsaco-2025-001784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2025] [Accepted: 03/30/2025] [Indexed: 04/23/2025] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of trauma-related morbidity and mortality worldwide, with decompressive craniectomy (DC) serving as a critical surgical intervention. This article reviews the recent studies evaluating the role of DC in the management of elevated intracranial pressures (ICPs) associated with TBI and its impact on functional outcomes. Decompressive Craniectomy in Diffuse Traumatic Brain Injury (DECRA), Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of intracranial pressure (RESCUEicp), and Randomized Evaluation of Surgery with Craniectomy for patients Undergoing Evacuation of Acute Subdural Hematoma (RESCUE-ASDH) are three landmark trials that used varying thresholds for surgical intervention after TBI and examined how functional outcomes improved with time. The DECRA trial evaluated early DC in patients with moderate ICP elevations, demonstrating reduced intensive care unit and hospital stays but poorer functional outcomes at 6 months. Conversely, the RESCUEicp trial emphasized the benefits of delayed DC as a rescue strategy for refractory ICP, showing reduced mortality and improved Glasgow Outcome Scale-Extended scores at 24 months. The RESCUE-ASDH trial compared DC and craniotomy for acute subdural hematoma, finding no significant differences in functional outcomes but distinct profiles of surgical complications. Key recommendations emphasize individualized decision-making based on patient-specific factors, including preinjury functional status and family involvement. This comprehensive review underscores the importance of tailoring DC timing and techniques to optimize functional recovery and align with patient-centered goals, advancing the multidisciplinary management of severe TBI.
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Affiliation(s)
| | - Tanya Egodage
- Surgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Matthew J Martin
- Division of Acute Care Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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Lin V, Hutchinson PJ, Kolias A, Robba C, Wahlster S. Timing of neurosurgical interventions for intracranial hypertension: the intensivists' and neurosurgeons' view. Curr Opin Crit Care 2025; 31:137-148. [PMID: 39991845 DOI: 10.1097/mcc.0000000000001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2025]
Abstract
PURPOSE OF REVIEW The aim of this study was to highlight clinical considerations regarding medical versus surgical management of elevated intracranial pressure (ICP), describe limitations of medical management, and summarize evidence regarding timing of neurosurgical interventions. RECENT FINDINGS The optimal ICP management strategy remains elusive, and substantial practice variations exist. Common risks of medical treatments include hypotension/shock, cardiac arrhythmias and heart failure, acute renal failure, volume overload, hypoxemia, and prolonged mechanical ventilation.In traumatic brain injury (TBI), recent randomized controlled trials (RCT) did not demonstrate outcome benefits for early, prophylactic decompressive craniectomy, but indicate a role for secondary decompressive craniectomy in patients with refractory elevated ICP. A recent meta-analysis suggested that when an extraventricular drain is required, insertion 24 h or less post-TBI may result in better outcomes.In large ischemic middle cerebral artery strokes, pooled analyses of three RCTs showed functional outcome benefits in patients less than 60 years who underwent prophylactic DC within less than 48 h. In intracranial hemorrhage, a recent RCT suggested outcome benefits for minimally invasive hematoma evacuation within less than 24 h. SUMMARY More data are needed to guide ICP targets, treatment modalities, predictors of herniation, and surgical triggers; clinical decisions should consider individual patient characteristics, and account for risks of medical and surgical treatments.
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Affiliation(s)
- Victor Lin
- University of Washington, Department of Neurology, Seattle, Washington, USA
| | - Peter John Hutchinson
- Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - Angelos Kolias
- Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - Chiara Robba
- IRCCS Policlinico San Martino
- Dipartimento di Scienze Chirurgiche Diagnostiche e Integrate, University of Genoa, Genova, Italy
| | - Sarah Wahlster
- University of Washington, Department of Neurology, Seattle, Washington, USA
- University of Washington, Department of Anesthesiology
- University of Washington, Department of Neurosurgery, Seattle, Washington, USA
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Svedung Wettervik T, Corell A, Sunila M, Enblad P, Velle F, Lindvall P, Kihlström Burenstam Linder L, Sæmundsson B, Fletcher-Sandersjöö A, Holmgren K. Decompressive craniectomy in aneurysmal subarachnoid hemorrhage: can favorable outcome be achieved? Acta Neurochir (Wien) 2025; 167:68. [PMID: 40069502 PMCID: PMC11897068 DOI: 10.1007/s00701-025-06485-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2025] [Accepted: 03/03/2025] [Indexed: 03/15/2025]
Abstract
BACKGROUND Decompressive craniectomy (DC) is a last-tier treatment for managing refractory intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage (aSAH), though concerns persist about whether it primarily prolongs survival in a state of severe disability. This study investigated patient characteristics, surgical indications, complications, and outcomes following DC in aSAH. METHODS In this Swedish, retrospective multi-center study, 123 aSAH patients treated with DC between 2008-2022 were included. Data collection included demographic details, aSAH characteristics, injury severity, DC indication, complications, and outcome at roughly six months post-DC (modified Rankin scale [mRS]) dichotomized as survival vs. mortality (0-5 vs. 6) and favorable vs. unfavorable (0-3 vs. 4-6). RESULTS The median age was 53 years and 66% were females. Two thirds presented with a WFNS grade 4-5 and 83% with a Fisher grade 4 hemorrhage. Most aneurysms were located at the middle cerebral artery (65%) and treated with clip ligation (59%). DC significantly reduced midline shift from 9 to 2 mm and obliteration rates of basal cisterns from 95 to 22% (p < 0.05). Reoperation for hematomas or extension of the DC were rare (< 5%). At follow-up, 20% were deceased, while 33% had recovered favorably. In univariate logistic regressions, younger age was associated with favorable outcome and reduced mortality. Other patient demographics, injury severity, and factors related to the DC surgery lacked association with outcome. CONCLUSIONS aSAH patients treated with DC presented with severe primary brain injuries and signs of intracranial hypertension. DC resulted in radiological improvements regarding mass effect and a low rate of postoperative complications. Although the results were based on a selected population of aSAH patients, an encouraging rate of favorable outcome was found, particularly among younger patients. However, the absence of additional outcome predictors underscores the ongoing challenges in improving patient selection for DC in aSAH.
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Affiliation(s)
| | - Alba Corell
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Merete Sunila
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Fartein Velle
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Peter Lindvall
- Department of Clinical Science - Neurosciences, Umeå University, Umeå, Sweden
| | - Lars Kihlström Burenstam Linder
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Bjartur Sæmundsson
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Klas Holmgren
- Department of Clinical Science - Neurosciences, Umeå University, Umeå, Sweden
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Agrawal S, Smith C, Bogli SY, Placek MM, Cabeleira M, White D, Daubney E, Young A, Beqiri E, Kayani R, O'Donnell D, Pathan N, Watson S, Maw A, Ganrett M, Kanthimathianathan HK, Bangalore H, Sundararajan S, Subramanian G, Raffaj D, Sarfatti A, Lampareillo S, Mayer A, Ross O, Czosnyka M, Hutchinson PJ, Smielewski P. Status of cerebrovascular autoregulation relates to outcome in severe paediatric head injury: STARSHIP, a prospective multicentre validation study. EClinicalMedicine 2025; 81:103077. [PMID: 39996125 PMCID: PMC11848105 DOI: 10.1016/j.eclinm.2025.103077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 12/17/2024] [Accepted: 01/10/2025] [Indexed: 02/26/2025] Open
Abstract
Background Continuous assessment of cerebral autoregulation (CA) using pressure reactivity index (PRx), is a promising tool for individualized management to improve outcome after traumatic brain injury (TBI). However, experience with CA in paediatric TBI (pTBI) is limited to retrospective or single-centre studies. Methods Studying Trends of AutoRegulation in Severe Head Injury in Paediatrics (STARSHIP) (clinicalTrials.gov identifier-NCT0688462), was a prospective, multicentre, observational, research database study conducted across 10 identified UK Paediatric Intensive Care Units from 01.07.2018 till 31.04.2024. The main objective was to validate and identify optimal thresholds of PRx associated with outcome (as assessed with Glasgow outcome scale extended for Pediatrics at 12 months) in children (<16 years) requiring invasive arterial blood pressure and intracranial pressure monitoring for TBI and establish a comprehensive research database. Apart from high-resolution data, clinical and outcome data up to 12 months post-ictus were collected. Univariable and multivariable analyses including propensity score matching, were employed to determine the effect of PRx on outcome whilst considering covariates, centre-specific differences and other multimodal metrics. Findings Out of 153 recruited, 135 children (median age 96 months) with consent and adequate data were included. Overall median PRx of the cohort was -0.09 (IQR -0.19 to 0.08). Both ICP and PRx were elevated in non-survivors and children with unfavourable outcome. PRx retained a significant effect on outcome after adjusting for various clinical and monitoring variables. The critical PRx threshold identified were 0.5 for mortality and 0.0 for favourable outcome. Interpretation With STARSHIP, we validate the outcome association of CA derangements as assessed by PRx in pTBI in the first prospective observational multicentre study. This provides additional evidence for the potential use of PRx for individualizing prognosis and treatment and pave way for further research in pTBI with the created database. Funding This study was funded by Action Medical Research for Children's Charity and Addenbrookes Charitable Trust, UK (Grant number-GN2609). Cambridge University Hospitals is the study sponsor (Reference: A094693, contact person: Michelle Ellerbeck-michelle.ellerbeck@nhs.net).
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Affiliation(s)
- Shruti Agrawal
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Paediatric Intensive Care, Cambridge University Hospitals, Cambridge, UK
| | - Claudia Smith
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan Y. Bogli
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Michal M. Placek
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Manuel Cabeleira
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Mechanical Engineering, University College London, London, UK
| | - Deborah White
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Paediatric Intensive Care, Cambridge University Hospitals, Cambridge, UK
| | - Esther Daubney
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Paediatric Intensive Care, Cambridge University Hospitals, Cambridge, UK
| | - Adam Young
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Erta Beqiri
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Riaz Kayani
- Paediatric Intensive Care, Cambridge University Hospitals, Cambridge, UK
| | - Diarmuid O'Donnell
- Paediatric Intensive Care, Cambridge University Hospitals, Cambridge, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Paediatric Intensive Care, Cambridge University Hospitals, Cambridge, UK
| | - Suzanna Watson
- Paediatric Neuropsychology, Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Anna Maw
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Matthew Ganrett
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Harish Bangalore
- Paediatric Intensive Care, Great Ormond Street Hospital, London, UK
| | | | | | - Dusan Raffaj
- Paediatric Intensive Care, Nottingham Children's Hospital, Nottingham, UK
| | - Avishay Sarfatti
- Paediatric Intensive Care, Oxford University Hospitals, Oxford, UK
| | | | - Anton Mayer
- Paediatric Intensive Care, Sheffield Children's Hospital, Sheffield, UK
| | - Oliver Ross
- Paediatric Intensive Care, Southampton General Hospital, Southampton, UK
| | - Marek Czosnyka
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter J. Hutchinson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Zhang L, Zhao H, Wang L, Shi Y, Li C. Time-to-surgery for traumatic brain injury in the hyperacute period: a systemic review and meta-analysis. Brain Inj 2025; 39:179-186. [PMID: 39514240 DOI: 10.1080/02699052.2024.2425735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 10/28/2024] [Accepted: 10/30/2024] [Indexed: 11/16/2024]
Abstract
OBJECTIVE To study the functional outcomes of traumatic brain injury (TBI) patients who have undergone surgical intervention in the hyperacute phase (<24 h). DATA SOURCES Cochrane Library, PubMed, Embase, Medline and Web of Science databases. REVIEW METHODS A meta-analysis of 7 trials involving 237 patients was performed. Patients were categorized into two groups based on time to surgery: within 6 h and within 24 h. Patients were also categorized into developed and developing regions. Effect estimates were calculated using a fixed-effects model and heterogeneity was assessed with Cochrane I² statistic. RESULTS Our findings revealed that those who underwent neurosurgery in the hyperacute phase of TBI were at risk of adverse outcomes. The odds ratio (OR) was 1.50 (95% CI 1.03-2.19). Subgroup analysis demonstrated that TBI patients who underwent surgery within 6 h were at a greater risk of adverse effects (OR, 1.72; 95% CI, 1.08-2.74). Moreover, a greater risk was observed in developing regions (OR, 2.33; 95% CI, 0.97-5.58). CONCLUSION Earlier neurosurgical intervention in the acute phase of TBI might result in higher incidence of adverse events. Surgery would be postponed for TBI patients whose initial GCS score is greater than 8 during the hyperacute period.
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Affiliation(s)
- Lijian Zhang
- Department of Neurosurgery, Clinical Medicine College, Affiliated Hospital of Hebei University, Baoding, Hebei, China
- Postdoctoral Research Station of Neurosurgery, Affiliated Hospital of Hebei University, Baoding, Hebei, China
- Key Laboratory of Precise Diagnosis and Treatment of Glioma in Hebei Province, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Hongfang Zhao
- Department of Neurosurgery, Clinical Medicine College, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Luxuan Wang
- Department of Neurological Function Examination, Clinical Medicine College, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Yanfang Shi
- Department of Neurosurgery, Clinical Medicine College, Affiliated Hospital of Hebei University, Baoding, Hebei, China
| | - Chunhui Li
- Department of Neurosurgery, Clinical Medicine College, Affiliated Hospital of Hebei University, Baoding, Hebei, China
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Pesonen EK, Lammi A, Qian C, Von und Zu Fraunberg M, Korhonen TK, Tetri S. Decompressive craniectomy in subarachnoid hemorrhage compared to other etiologies: An institutional experience of 11 years. BRAIN & SPINE 2025; 5:104203. [PMID: 40007802 PMCID: PMC11850783 DOI: 10.1016/j.bas.2025.104203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 01/30/2025] [Accepted: 02/03/2025] [Indexed: 02/27/2025]
Abstract
Introduction Decompressive craniectomy (DC) is a last-tier procedure to lower intracranial pressure in otherwise fatal brain injuries. DC significantly reduces mortality following traumatic brain injury (TBI) and ischemic stroke, but benefits in subarachnoid hemorrhage (SAH) are less clear. Research question We compared the mortality and functional outcomes in patients who underwent DC after SAH with those who underwent DC following TBI or ischemic stroke. Materials and methods All DC procedures performed in the Oulu University Hospital between January 2009 and December 2019 were retrospectively identified. Mortality and functional outcomes were assessed during a median follow-up of 20.7 months. Extended Glasgow Outcome Scale scores ≥5 were considered favorable. Results One hundred twenty-four DCs were conducted to patients aged a median of 40 years (SD 16), of whom 88 (71%) were male. Fifty-eight (47%) DCs were due to TBI and 66 (53%) due to stroke. Of the strokes, 41 (62%) were ischemic and 21 (32%) SAH.In multivariate models, the rates of unfavorable outcome were 48% in TBI, 78% in ischemic stroke (OR 2.73, 95% CI 0.70-10.64) and 86% in SAH (OR 3.15, 95%CI 0.67-14.77). Mortality rates were 22% in TBI, 17% in ischemic stroke (OR 0.50, 95%CI 0.11-2.31) and 33% in SAH (OR 0.97, 95%CI 0.24-3.99). Discussion and conclusion Favorable outcomes were more common in TBI compared to stroke in univariate but not in multivariate analysis. There was no statistically significant difference in the rates of favorable outcomes between SAH and ischemic stroke.
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Affiliation(s)
| | | | - Cheng Qian
- Department of Neurosurgery, Oulu University Hospital & University of Oulu, Kajaanintie 52, 90029, Oulu, Finland
| | - Mikael Von und Zu Fraunberg
- Department of Neurosurgery, Oulu University Hospital & University of Oulu, Kajaanintie 52, 90029, Oulu, Finland
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de Carvalho Panzeri Carlotti AP, do Amaral VH, de Carvalho Canela Balzi AP, Johnston C, Regalio FA, Cardoso MF, Ferranti JF, Zamberlan P, Gilio AE, Malbouisson LMS, Delgado AF, de Carvalho WB. Management of severe traumatic brain injury in pediatric patients: an evidence-based approach. Neurol Sci 2025; 46:969-991. [PMID: 39476094 DOI: 10.1007/s10072-024-07849-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 10/20/2024] [Indexed: 01/28/2025]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of death and disability worldwide. The decision-making process in the management of severe TBI must be based on the best available evidence to minimize the occurrence of secondary brain injuries. However, healthcare approaches to managing TBI patients exhibit considerable variation. METHODS Over an 18-month period, a multidisciplinary panel consisting of medical doctors, physiotherapists, nutritional therapists, and nurses performed a comprehensive review on various subtopics concerning TBI. The panel identified primary questions to be addressed using the Population, Intervention, Control, and Outcome (PICO) format and applied the Evidence to Decision (EtD) framework criteria for evaluating interventions. Subsequently, the panel formulated recommendations for the management of severe TBI in children. RESULTS Fourteen evidence-based recommendations have been devised for the management of severe TBI in children, covering nine topics, including imaging studies, neuromonitoring, prophylactic anticonvulsant use, hyperosmolar therapy, sedation and analgesia, mechanical ventilation strategies, nutritional therapy, blood transfusion, and decompressive craniectomy. For each topic, the panel provided clinical recommendations and identified research priorities. CONCLUSIONS This review offers evidence-based strategies aimed to guide practitioners in the care of children who suffer from severe TBI.
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Affiliation(s)
- Ana Paula de Carvalho Panzeri Carlotti
- Division of Critical Care Medicine, Department of Pediatrics, Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil.
| | - Vivian Henriques do Amaral
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Ana Paula de Carvalho Canela Balzi
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Cintia Johnston
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Fabiane Allioti Regalio
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Maíra Freire Cardoso
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Juliana Ferreira Ferranti
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Patrícia Zamberlan
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Alfredo Elias Gilio
- Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Artur Figueiredo Delgado
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Werther Brunow de Carvalho
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
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Guo J, Hou X, Zeng J, Chen X, Zheng S, Xu B, Zheng S, Liu Z, Ling G. A Retrospective Study on Subgaleal Fluid Collection After Titanium Mesh and Polyetheretherketone Cranioplasty. World Neurosurg 2025; 194:123538. [PMID: 39643208 DOI: 10.1016/j.wneu.2024.11.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2024] [Accepted: 11/29/2024] [Indexed: 12/09/2024]
Abstract
OBJECTIVE Cranioplasty is a common neurosurgical procedure aimed at providing structural protection to cerebral tissues and enhancing neurological function. The choice of implant material, particularly polyetheretherketone (PEEK) and titanium mesh, significantly influences postoperative outcomes, including the incidence of subgaleal fluid collections (SFC). This study investigates the incidence of SFC associated with PEEK and titanium mesh in cranioplasty, identifying risk factors and implications for clinical practice. METHODS A retrospective analysis was conducted on 70 patients who underwent cranioplasty. The incidence of SFC, postoperative complications, and demographic data were collected and analyzed. Statistical comparisons were made between the 2 implant materials. RESULTS The incidence of SFC was significantly higher in the PEEK group (46.2%) compared to the titanium mesh group (20.5%) (P = 0.023). PEEK was identified as an independent risk factor for SFC. Additionally, approximately 60% of postoperative epidural hematoma cases presented with SFC, highlighting the importance of meticulous hemostasis during surgery. The overall reoperation rate was 5.7%, consistent with existing literature. Although diabetes mellitus did not show a statistically significant association with SFC (P = 0.064), its potential impact on postoperative complications warrants further investigation. CONCLUSIONS The selection of implant materials in cranioplasty significantly affects postoperative outcomes, with PEEK associated with a higher incidence of SFC. Careful material selection, particularly in patients with comorbidities, and meticulous surgical techniques are essential to improve patient outcomes. Future research should focus on the biological interactions between implant materials and cranial tissues to refine guidelines for clinical practice.
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Affiliation(s)
- Jian Guo
- Department of Neurosurgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Xu Hou
- Department of Neurosurgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Junying Zeng
- Department of Internal medicine, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Xiaodong Chen
- Department of Internal medicine, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Shizhong Zheng
- Department of Neurosurgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Bingchu Xu
- Department of Neurosurgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Shoulian Zheng
- Department of Neurosurgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Zhiliang Liu
- Department of Neurosurgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Gengqiang Ling
- Department of Neurosurgery, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China.
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Schievink WI, Maya MM, Babadjouni R, Tay ASS, Taché RB. Skull defect - Frontotemporal dementia sagging brain syndrome. Ann Clin Transl Neurol 2025; 12:226-234. [PMID: 39675020 PMCID: PMC11752090 DOI: 10.1002/acn3.52277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Revised: 10/25/2024] [Accepted: 11/24/2024] [Indexed: 12/17/2024] Open
Abstract
OBJECTIVE Frontotemporal dementia (FTD) sagging brain syndrome is a disabling condition. An underlying spinal Cerebrospinal fluid leak can be identified in only a minority of patients and the success rate of non-directed treatments is low. Some of these patients have a remote history of craniectomy/cranioplasty and we report a positive response to custom implant cranioplasty revision many years after their initial cranioplasty. METHODS We reviewed medical records and imaging studies of 61 consecutive patients with FTD sagging brain syndrome. A SIH Disability Assessment Score (SIHDAS) questionnaire was completed to assess the severity of the symptoms before and after custom implant cranioplasty. Pre- and post-operative brain MRI was obtained to assess degree of brain sagging. RESULTS Eight (13.1%) of the 61 patients had a history of craniectomy/cranioplasty 1.5-13.5 years prior to onset of symptoms of FTD sagging brain syndrome. The mean age of the one woman and seven men at the time of presentation to our medical center was 50 years (range, 26-68 years). None had sinking scalp flap syndrome. Prior treatments included epidural blood patching and dural reduction surgery. Custom cranial implant surgery was performed in four patients and resulted in prompt and remarkable improvement of symptoms in three patients (SIHDAS: very severe disability to no or mild disability) and mild improvement in one patient. Brain MRI showed improvement of brain sagging. INTERPRETATION A disproportionate number of patients with FTD sagging brain syndrome have a remote history of supratentorial craniectomy/cranioplasty and revision cranioplasty should be considered.
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Affiliation(s)
- Wouter I. Schievink
- Department of NeurosurgeryCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Marcel M. Maya
- Department of ImagingCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | - Robin Babadjouni
- Department of NeurosurgeryCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | | | - Rachelle B. Taché
- Department of NeurosurgeryCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
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Johnson-Black PH, Carlson JM, Vespa PM. Traumatic brain injury and disorders of consciousness. HANDBOOK OF CLINICAL NEUROLOGY 2025; 207:75-96. [PMID: 39986729 DOI: 10.1016/b978-0-443-13408-1.00014-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2025]
Abstract
Trauma is one of the most common causes of disorders of consciousness (DOC) worldwide. Traumatic brain injury (TBI) leads to heterogeneous, multifocal injury via focal brain damage and diffuse axonal injury, causing an acquired network disorder. Recovery occurs through reemergence of dynamic cortical and subcortical networks. Accurate diagnostic evaluation is essential toward promoting recovery and may be more challenging in traumatic than non-traumatic brain injuries. Standardized neurobehavioral assessment is the cornerstone for assessments in the acute, prolonged, and chronic phases of traumatic DOC, while structural and functional neuroimaging, tractography, nuclear medicine studies, and electrophysiologic techniques assist with differentiation of DOC states and prognostication. Prognosis for recovery is better for patients with TBI than those with non-traumatic brain injuries, and the timeline for recovery is longer. The majority of patients experience improvement in their DOC within the first year post-injury, but recovery can continue for five and even ten years after TBI. Pharmacologic therapy and device-related neuromodulation represent important areas for future research.
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Affiliation(s)
- Phoebe H Johnson-Black
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Julia M Carlson
- Department of Neurology, UNC Neurorecovery Clinic, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Paul M Vespa
- Assistant Dean of Research in Critical Care, Gary L. Brinderson Family Chair in Neurocritical Care, Department of Neurosurgery and Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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11
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Lv E, Xue X, Xu Z, Liu H. Ultrasound-Guided Percutaneous Puncture Combined With Continuous Pressure Dressing for Treating Subcutaneous Fluid Accumulation in the Bone Window Area After Decompressive Craniectomy. J Craniofac Surg 2024:00001665-990000000-02310. [PMID: 39729284 DOI: 10.1097/scs.0000000000011058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2024] [Accepted: 12/14/2024] [Indexed: 12/28/2024] Open
Abstract
Subcutaneous fluid accumulation in the bone window area is a common complication after decompressive craniectomy. If not promptly addressed, it may progress to serious complications such as intracranial infection and hydrocephalus, significantly affecting treatment outcomes and prognosis. However, there is currently no standardized approach for managing subcutaneous fluid accumulation. Ultrasound-guided percutaneous puncture in the bone window area can directly decrease the accumulated fluid; moreover, when combined with continuous pressure dressing, this approach can effectively eliminate subcutaneous fluid in a short period, prevent severe complications, and enhance patient recovery outcomes.
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Affiliation(s)
- Enzhen Lv
- Dezhou Seventh People's Hospital, Dezhou City, Shandong Province, China
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12
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Cáceres E, Divani AA, Rubinos CA, Olivella-Gómez J, Viñan Garcés AE, González A, Alvarado Arias A, Bhatia K, Samadani U, Reyes LF. PaCO 2 Association with Outcomes of Patients with Traumatic Brain Injury at High Altitude: A Prospective Single-Center Cohort Study. Neurocrit Care 2024; 41:767-778. [PMID: 38740704 PMCID: PMC11599390 DOI: 10.1007/s12028-024-01982-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/12/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Partial pressure of carbon dioxide (PaCO2) is generally known to influence outcome in patients with traumatic brain injury (TBI) at normal altitudes. Less is known about specific relationships of PaCO2 levels and clinical outcomes at high altitudes. METHODS This is a prospective single-center cohort of consecutive patients with TBI admitted to a trauma center located at 2600 m above sea level. An unfavorable outcome was defined as a Glasgow Outcome Scale-Extended (GOSE) score < 4 at the 6-month follow-up. RESULTS We had a total of 81 patients with complete data, 80% (65/81) were men, and the median (interquartile range) age was 36 (25-50) years. Median Glasgow Coma Scale (GCS) score on admission was 9 (6-14); 49% (40/81) of patients had severe TBI (GCS 3-8), 32% (26/81) had moderate TBI (GCS 12-9), and 18% (15/81) had mild TBI (GCS 13-15). The median (interquartile range) Abbreviated Injury Score of the head (AISh) was 3 (2-4). The frequency of an unfavorable outcome (GOSE < 4) was 30% (25/81), the median GOSE was 4 (2-5), and the median 6-month mortality rate was 24% (20/81). Comparison between patients with favorable and unfavorable outcomes revealed that those with unfavorable outcome were older, (median age 49 [30-72] vs. 29 [22-41] years, P < 0.01), had lower admission GCS scores (6 [4-8] vs. 13 [8-15], P < 0.01), had higher AISh scores (4 [4-4] vs. 3 [2-4], P < 0.01), had higher Acute Physiology and Chronic Health disease Classification System II scores (17 [15-23] vs. 10 [6-14], P < 0.01), had higher Charlson scores (0 [0-2] vs. 0 [0-0], P < 0.01), and had higher PaCO2 levels (mean 35 ± 8 vs. 32 ± 6 mm Hg, P < 0.01). In a multivariate analysis, age (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.1-1.30, P < 0.01), AISh (OR 4.7, 95% CI 1.55-21.0, P < 0.05), and PaCO2 levels (OR 1.23, 95% CI 1.10-1.53, P < 0.05) were significantly associated with the unfavorable outcomes. When applying the same analysis to the subgroup on mechanical ventilation, AISh (OR 5.4, 95% CI 1.61-28.5, P = 0.017) and PaCO2 levels (OR 1.36, 95% CI 1.13-1.78, P = 0.015) remained significantly associated with the unfavorable outcome. CONCLUSIONS Higher PaCO2 levels are associated with an unfavorable outcome in ventilated patients with TBI. These results underscore the importance of PaCO2 levels in patients with TBI and whether it should be adjusted for populations living at higher altitudes.
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Affiliation(s)
- Eder Cáceres
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chía, Colombia.
- Department of Bioscience, School of Engineering, Universidad de La Sabana, Chía, Colombia.
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia.
| | - Afshin A Divani
- Department of Neurology, The University of New Mexico, Albuquerque, NM, USA
| | - Clio A Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Juan Olivella-Gómez
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
| | | | - Angélica González
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
| | | | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Uzma Samadani
- Department of Neurosurgery, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Luis F Reyes
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chía, Colombia
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
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13
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Yue JK, Kanter JH, Barber JK, Huang MC, van Essen TA, Elguindy MM, Foreman B, Korley FK, Belton PJ, Pisică D, Lee YM, Kitagawa RS, Vassar MJ, Sun X, Satris GG, Wong JC, Ferguson AR, Huie JR, Wang KK, Deng H, Wang VY, Bodien YG, Taylor SR, Madhok DY, McCrea MA, Ngwenya LB, DiGiorgio AM, Tarapore PE, Stein MB, Puccio AM, Giacino JT, Diaz-Arrastia R, Lingsma HF, Mukherjee P, Yuh EL, Robertson CS, Menon DK, Maas AI, Markowitz AJ, Jain S, Okonkwo DO, Temkin NR, Manley GT. Clinical profile of patients with acute traumatic brain injury undergoing cranial surgery in the United States: report from the 18-centre TRACK-TBI cohort study. LANCET REGIONAL HEALTH. AMERICAS 2024; 39:100915. [PMID: 39497836 PMCID: PMC11532273 DOI: 10.1016/j.lana.2024.100915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 10/02/2024] [Accepted: 10/03/2024] [Indexed: 11/07/2024]
Abstract
Background Contemporary surgical practices for traumatic brain injury (TBI) remain unclear. We describe the clinical profile of an 18-centre US TBI cohort with cranial surgery. Methods The prospective, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (2014-2018; ClinicalTrials.gov #NCT02119182) enrolled subjects who presented to trauma centre and received head computed tomography within 24-h (h) post-TBI. We performed a secondary data analysis in subjects aged ≥17-years with hospitalisation. Clinical characteristics, surgery type/timing, hospital and six-month outcomes were reported. Findings Of 2032 subjects (age: mean = 41.4-years, range = 17-89-years; male = 71% female = 29%), 260 underwent cranial surgery, comprising 65% decompressive craniectomy, 23% craniotomy, 12% other surgery. Subjects with surgery (vs. without surgery) presented with worse neurological injury (median Glasgow Coma Scale = 6 vs. 15; midline shift ≥5 mm: 48% vs. 2%; cisternal effacement: 61% vs. 4%; p < 0.0001). Median time-to-craniectomy/craniotomy was 1.8 h (interquartile range = 1.1-5.0 h), and 67% underwent intracranial pressure monitoring. Seventy-three percent of subjects with decompressive craniectomy and 58% of subjects with craniotomy had ≥3 intracranial lesion types. Decompressive craniectomy (vs. craniotomy) was associated with intracranial injury severity (median Rotterdam Score = 4 vs. 3, p < 0.0001), intensive care length of stay (median = 13 vs. 4-days, p = 0.0002), and six-month unfavourable outcome (62% vs. 30%; p = 0.0001). Earlier time-to-craniectomy was associated with intracranial injury severity. Interpretation In a large representative cohort of patients hospitalised with TBI, surgical decision-making and time-to-surgery aligned with intracranial injury severity. Multifocal TBIs predominated in patients with cranial surgery. These findings summarise current TBI surgical practice across US trauma centres and provide the foundation for analyses in targeted subpopulations. Funding National Institute of Neurological Disorders and Stroke; US Department of Defense; Neurosurgery Research and Education Foundation.
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Affiliation(s)
- John K. Yue
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - John H. Kanter
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Jason K. Barber
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle, WA, United States
| | - Michael C. Huang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Thomas A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden, The Hague, the Netherlands
- Department of Surgery, Division of Neurosurgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mahmoud M. Elguindy
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Brandon Foreman
- Department of Neurology, University of Cincinnati, Cincinnati, OH, United States
| | - Frederick K. Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Patrick J. Belton
- Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States
| | - Dana Pisică
- Center for Medical Decision Making, Department of Epidemiology and Public Health, Erasmus MC, University Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Young M. Lee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Ryan S. Kitagawa
- Department of Neurological Surgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Mary J. Vassar
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, CA, United States
| | - Gabriela G. Satris
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Justin C. Wong
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Adam R. Ferguson
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - J. Russell Huie
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Kevin K.W. Wang
- Department of Neurobiology, Morehouse School of Medicine, Atlanta, GA, United States
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Vincent Y. Wang
- Department of Neurological Surgery, University of Texas at Austin, Austin, TX, United States
| | - Yelena G. Bodien
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Sabrina R. Taylor
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Debbie Y. Madhok
- Departments of Emergency Medicine and Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Michael A. McCrea
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Laura B. Ngwenya
- Department of Neurological Surgery, University of Cincinnati, Cincinnati, OH, United States
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, United States
| | - Ava M. Puccio
- Department of Neurobiology, Morehouse School of Medicine, Atlanta, GA, United States
| | - Joseph T. Giacino
- Department of Rehabilitation Medicine, Spaulding Rehabilitation Center, Boston, MA, United States
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Hester F. Lingsma
- Center for Medical Decision Making, Department of Epidemiology and Public Health, Erasmus MC, University Center Rotterdam, Rotterdam, the Netherlands
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Claudia S. Robertson
- Department of Neurological Surgery, Baylor College of Medicine, Houston, TX, United States
| | - David K. Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Andrew I.R. Maas
- Department of Neurological Surgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, University of Antwerp, Antwerp, Belgium
| | - Amy J. Markowitz
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, La Jolla, CA, United States
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Nancy R. Temkin
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle, WA, United States
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, United States
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Wart M, Edwards TH, Rizzo JA, Peitz GW, Pigott A, Levine JM, Jeffery ND. Traumatic brain injury in companion animals: Pathophysiology and treatment. Top Companion Anim Med 2024; 63:100927. [PMID: 39461414 DOI: 10.1016/j.tcam.2024.100927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 10/01/2024] [Accepted: 10/22/2024] [Indexed: 10/29/2024]
Abstract
Traumatic brain injuries (TBI) are common in dogs and cats that have sustained head trauma from a variety of causes. In moderate to severe TBI, damage from both the primary and secondary injuries can be life-threatening. TBI management may be further complicated by concurrent injuries in polytrauma patients. Thorough initial and serial examinations are key in detecting neurologic changes quickly and guiding treatment. Intensive treatments such as nursing care, fluid therapy, hyperosmolar agents, analgesia, sedation, anticonvulsants, oxygen supplementation, surgery, and rehabilitation may be employed in TBI management. Prognostication resources for an individual patient are limited and a perceived poor prognosis may worsen clinical outcomes. In this paper, we review the pathophysiology of TBI, identification, injury stratification and prognosis of patients with TBI as well as propose treatment and monitoring recommendations for companion animals based on severity of TBI.
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Affiliation(s)
- Molly Wart
- School of Veterinary Medicine, Texas A&M University, College Station, TX.
| | - Thomas H Edwards
- School of Veterinary Medicine, Texas A&M University, College Station, TX; US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | - Julie A Rizzo
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX
| | | | - Armi Pigott
- College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - Jonathan M Levine
- School of Veterinary Medicine, Texas A&M University, College Station, TX
| | - Nicholas D Jeffery
- School of Veterinary Medicine, Texas A&M University, College Station, TX
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15
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Caldas J, Cardim D, Edmundson P, Morales J, Feng A, Ashley JD, Park C, Valadka A, Foreman M, Cullum M, Sharma K, Liu Y, Zhu D, Zhang R, Ding K. Study protocol: Cerebral autoregulation, brain perfusion, and neurocognitive outcomes after traumatic brain injury -CAPCOG-TBI. Front Neurol 2024; 15:1465226. [PMID: 39479003 PMCID: PMC11521900 DOI: 10.3389/fneur.2024.1465226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 09/27/2024] [Indexed: 11/02/2024] Open
Abstract
Background Moderate-severe traumatic brain injury (msTBI) stands as a prominent etiology of adult disability, with increased risk for cognitive impairment and dementia. Although some recovery often occurs within the first year post-injury, predicting long-term cognitive outcomes remains challenging, partly due to the significant pathophysiological heterogeneity of TBI, including acute cerebrovascular injury. The primary aim of our recently funded study, cerebral autoregulation, brain perfusion, and neurocognitive outcomes after traumatic brain injury (CAPCOG-TBI), is to determine if acute cerebrovascular dysfunction after msTBI measured using multimodal non-invasive neuromonitoring is associated with cognitive outcome at 1-year post-injury. Methods This longitudinal observational study will be conducted at two Level 1 trauma centers in Texas, USA, and will include adult patients with msTBI, and/or mild TBI with neuroimaging abnormalities. Multimodal cerebral vascular assessment using transcranial Doppler and cerebral near-infrared spectroscopy (NIRS) will be conducted within 7-days of onset of TBI. Longitudinal outcomes, including cognitive/functional assessments (Glasgow Outcome Scale and Patient-Reported Outcomes Measurement Information System), cerebral vascular assessment, and imaging will be performed at follow-ups 3-, 6-, and 12-months post-injury. We aim to recruit 100 subjects with msTBI along with 30 orthopedic trauma controls (OTC). This study is funded by National Institute of Neurological Disease and Stroke (NINDS) and is registered on Clinicaltrial.org (NCT06480838). Expected results We anticipate that msTBI patients will exhibit impaired cerebrovascular function in the acute phase compared to the OTC group. The severity of cerebrovascular dysfunction during this stage is expected to inversely correlate with cognitive and functional outcomes at 1-year post-injury. Additionally, recovery from cerebrovascular dysfunction is expected to be linked to cognitive recovery. Conclusion The results of this study could help to understand the contribution of cerebrovascular dysfunction to cognitive outcomes after TBI and pave the way for innovative vascular-focused interventions aimed at enhancing cognitive recovery and mitigating neurodegeneration following msTB. In addition, its focus toward personalized medicine to aid in the management and prognosis of TBI patients.
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Affiliation(s)
- Juliana Caldas
- University of Texas Southwestern Medical Center, Dallas, TX, United States
- Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil
- D'or Institute for Research and Teaching, Salvador, Bahia, Brazil
| | - Danilo Cardim
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | - Jill Morales
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Aaron Feng
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | - Caroline Park
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Alex Valadka
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | - Munro Cullum
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kartavya Sharma
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Yulun Liu
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - David Zhu
- Albert Einstein College of Medicine, New York, NY, United States
| | - Rong Zhang
- University of Texas Southwestern Medical Center, Dallas, TX, United States
- Texas Health Resources, Dallas, TX, United States
| | - Kan Ding
- University of Texas Southwestern Medical Center, Dallas, TX, United States
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16
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Suryavanshi P, Langton R, Fairhead K, Glykys J. Brief and Diverse Excitotoxic Insults Increase the Neuronal Nuclear Membrane Permeability in the Neonatal Brain, Resulting in Neuronal Dysfunction and Cell Death. J Neurosci 2024; 44:e0350242024. [PMID: 39214703 PMCID: PMC11466074 DOI: 10.1523/jneurosci.0350-24.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 08/16/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024] Open
Abstract
Neuronal cytotoxic edema is implicated in neuronal injury and death, yet mitigating brain edema with osmotic and surgical interventions yields poor clinical outcomes. Importantly, neuronal swelling and its downstream consequences during early brain development remain poorly investigated, and new treatment approaches are needed. We explored Ca2+-dependent downstream effects after neuronal cytotoxic edema caused by diverse injuries in mice of both sexes using multiphoton Ca2+ imaging in vivo [Postnatal Day (P)12-17] and in acute brain slices (P8-12). After different excitotoxic insults, cytosolic GCaMP6s translocated into the nucleus after a few minutes in a subpopulation of neurons, persisting for hours. We used an automated morphology-detection algorithm to detect neuronal soma and quantified the nuclear translocation of GCaMP6s as the nuclear to cytosolic intensity (N/C ratio). Elevated neuronal N/C ratios occurred concurrently with persistent elevation in Ca2+ loads and could also occur independently from neuronal swelling. Electron microscopy revealed that the nuclear translocation was associated with the increased nuclear pore size. The nuclear accumulation of GCaMP6s in neurons led to neocortical circuit dysfunction, mitochondrial pathology, and increased cell death. Inhibiting calpains, a family of Ca2+-activated proteases, prevented elevated N/C ratios and neuronal swelling. In summary, in the developing brain, we identified a calpain-dependent alteration of nuclear transport in a subpopulation of neurons after disease-relevant insults leading to long-term circuit dysfunction and cell death. The nuclear translocation of GCaMP6 and other cytosolic proteins after acute excitotoxicity can be an early biomarker of brain injury in the developing brain.
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Affiliation(s)
- Pratyush Suryavanshi
- Department of Pediatrics, The University of Iowa, Iowa City, Iowa 52242
- Iowa Neuroscience Institute, The University of Iowa, Iowa City, Iowa 52242
| | - Rachel Langton
- Department of Pediatrics, The University of Iowa, Iowa City, Iowa 52242
- Iowa Neuroscience Institute, The University of Iowa, Iowa City, Iowa 52242
| | - Kimberly Fairhead
- Biomedical Sciences, College of Liberal Arts and Sciences, The University of Iowa, Iowa City, Iowa 52242
| | - Joseph Glykys
- Department of Pediatrics, The University of Iowa, Iowa City, Iowa 52242
- Iowa Neuroscience Institute, The University of Iowa, Iowa City, Iowa 52242
- Department of Neurology, The University of Iowa, Iowa City, Iowa 52242
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Zhu S, Liu X, Lu X, Liao Q, Luo H, Tian Y, Cheng X, Jiang Y, Liu G, Chen J. Biomaterials and tissue engineering in traumatic brain injury: novel perspectives on promoting neural regeneration. Neural Regen Res 2024; 19:2157-2174. [PMID: 38488550 PMCID: PMC11034597 DOI: 10.4103/1673-5374.391179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/13/2023] [Accepted: 11/20/2023] [Indexed: 04/24/2024] Open
Abstract
Traumatic brain injury is a serious medical condition that can be attributed to falls, motor vehicle accidents, sports injuries and acts of violence, causing a series of neural injuries and neuropsychiatric symptoms. However, limited accessibility to the injury sites, complicated histological and anatomical structure, intricate cellular and extracellular milieu, lack of regenerative capacity in the native cells, vast variety of damage routes, and the insufficient time available for treatment have restricted the widespread application of several therapeutic methods in cases of central nervous system injury. Tissue engineering and regenerative medicine have emerged as innovative approaches in the field of nerve regeneration. By combining biomaterials, stem cells, and growth factors, these approaches have provided a platform for developing effective treatments for neural injuries, which can offer the potential to restore neural function, improve patient outcomes, and reduce the need for drugs and invasive surgical procedures. Biomaterials have shown advantages in promoting neural development, inhibiting glial scar formation, and providing a suitable biomimetic neural microenvironment, which makes their application promising in the field of neural regeneration. For instance, bioactive scaffolds loaded with stem cells can provide a biocompatible and biodegradable milieu. Furthermore, stem cells-derived exosomes combine the advantages of stem cells, avoid the risk of immune rejection, cooperate with biomaterials to enhance their biological functions, and exert stable functions, thereby inducing angiogenesis and neural regeneration in patients with traumatic brain injury and promoting the recovery of brain function. Unfortunately, biomaterials have shown positive effects in the laboratory, but when similar materials are used in clinical studies of human central nervous system regeneration, their efficacy is unsatisfactory. Here, we review the characteristics and properties of various bioactive materials, followed by the introduction of applications based on biochemistry and cell molecules, and discuss the emerging role of biomaterials in promoting neural regeneration. Further, we summarize the adaptive biomaterials infused with exosomes produced from stem cells and stem cells themselves for the treatment of traumatic brain injury. Finally, we present the main limitations of biomaterials for the treatment of traumatic brain injury and offer insights into their future potential.
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Affiliation(s)
- Shihong Zhu
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaoyin Liu
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiyue Lu
- Department of Anesthesiology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Qiang Liao
- Department of Pharmacy, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Huiyang Luo
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
- Department of Anesthesiology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Yuan Tian
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Xu Cheng
- Department of Anesthesiology, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Yaxin Jiang
- Out-patient Department, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Guangdi Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
| | - Jing Chen
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan Province, China
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18
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Jelmoni AJ, Cannizzaro D, Uralov D, Totis F, Safa A, Zaed I, Fauzi AA, Khan T, Esene IN, Kolias A, Karekezi C, Hutchinson P, Servadei F. Collaborative Initiatives in Neurosurgery Research and Publications Between High-Income and Low/Middle-Income Countries: A Bibliometric Analysis. Neurosurgery 2024; 95:e121-e131. [PMID: 39283118 PMCID: PMC11377094 DOI: 10.1227/neu.0000000000002935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/01/2024] [Indexed: 09/22/2024] Open
Abstract
Despite the globalization of health information, collaborations between high-income countries (HICs) and low/middle-income countries (LMICs), while present, could still increase. This study builds on previous research highlighting LMIC underrepresentation in neurosurgery literature. We conducted a comprehensive bibliometric analysis using the Scopus database to investigate collaborative neurosurgical research between HIC institutions and those in low-income country (LIC)/LMICs. Articles published between 2018 and 2020 were examined. Articles were categorized into 3 groups: guidelines, conferences, and consensus statements; articles related to training and collaborations; and other articles. We categorized articles and authors by country, role, and specific subtopic. We included 238 reports from 34 neurosurgical journals for analysis. Geographic distribution indicated that India led LIC/LMIC contributions (25.21%). Among HICs, the United States had the highest contribution (47.76%). In collaborative studies, Uganda, Cameroon, Tanzania, Indonesia, and Nigeria made significant contributions. LICs and LMICs accounted for 446 authors, while HICs contributed with 592. India has presented the highest number of authors in significant positions. In HICs, significant positions are recognized in USA articles. When scoring authors' position in collaborative papers, still HICs had a clear prevalence. The highest number of collaborations between HICs and LICs/LMICs has been observed in articles related to training and collaborations. Kenya matched India's contributions in training and collaborations. Global guidelines and consensus papers can enhance patient care, but LMICs' involvement remains limited. Further attention to training and collaboration initiatives is needed. This study emphasizes the importance of promoting collaboration and training between countries with varying resources to advance neurosurgical care globally.
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Affiliation(s)
| | - Delia Cannizzaro
- Neurosurgical Unit, Department of Neurosciences, ASST Ovest Milanese - Legnano Hospital, Legnano, Italy
| | - Daniel Uralov
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Francesca Totis
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Adrian Safa
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Ismail Zaed
- Department of Neurosurgery, Neurocenter of South Switzerland, EOC, Lugano, Switzerland
| | - Asra Al Fauzi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Tariq Khan
- Department of Neurosurgery, North Western General and Research Hospital, Peshawar, Pakistan
| | - Ignatius N. Esene
- Neurosurgery Division, Faculty of Health Sciences, University of Bamenda, Bambili, Cameroon
| | - Angelos Kolias
- NIHR Global Health Research Group on Acquired Brain and Spine Injury, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Claire Karekezi
- Neurosurgery Unit, Department of Surgery, Rwanda Military Hospital, University of Rwanda, Kigali, Rwanda
| | - Peter Hutchinson
- NIHR Global Health Research Group on Acquired Brain and Spine Injury, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
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19
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Solomou G, Sunny J, Mohan M, Hossain I, Kolias AG, Hutchinson PJ. Decompressive craniectomy in trauma: What you need to know. J Trauma Acute Care Surg 2024; 97:490-496. [PMID: 39137371 PMCID: PMC11446508 DOI: 10.1097/ta.0000000000004357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/23/2024] [Accepted: 04/01/2024] [Indexed: 08/15/2024]
Abstract
ABSTRACT Decompressive craniectomy (DC) is a surgical procedure in which a large section of the skull is removed, and the underlying dura mater is opened widely. After evacuating a traumatic acute subdural hematoma, a primary DC is typically performed if the brain is bulging or if brain swelling is expected over the next several days. However, a recent randomized trial found similar 12-month outcomes when primary DC was compared with craniotomy for acute subdural hematoma. Secondary removal of the bone flap was performed in 9% of the craniotomy group, but more wound complications occurred in the craniectomy group. Two further multicenter trials found that, whereas early neuroprotective bifrontal DC for mild to moderate intracranial hypertension is not superior to medical management, DC as a last-tier therapy for refractory intracranial hypertension leads to reduced mortality. Patients undergoing secondary last-tier DC are more likely to improve over time than those in the standard medical management group. The overall conclusion from the most up-to-date evidence is that secondary DC has a role in the management of intracranial hypertension following traumatic brain injury but is not a panacea. Therefore, the decision to offer this operation should be made on a case-by-case basis. Following DC, cranioplasty is warranted but not always feasible, especially in low- and middle-income countries. Consequently, a decompressive craniotomy, where the bone flap is allowed to "hinge" or "float," is sometimes used. Decompressive craniotomy is also an option in a subgroup of traumatic brain injury patients undergoing primary surgical evacuation when the brain is neither bulging nor relaxed. However, a high-quality randomized controlled trial is needed to delineate the specific indications and the type of decompressive craniotomy in appropriate patients.
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20
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Yathindra MR, Sabu N, Lakshmy S, Gibson CA, Morris AT, Farah Fatima S, Gupta A, Ghazaryan L, Daher JC, Tello Seminario G, Mahajan T, Siddiqui HF. Navigating the Role of Surgery in Optimizing Patient Outcomes in Traumatic Brain Injuries (TBIs): A Comprehensive Review. Cureus 2024; 16:e71234. [PMID: 39525257 PMCID: PMC11550374 DOI: 10.7759/cureus.71234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2024] [Indexed: 11/16/2024] Open
Abstract
Traumatic brain injuries (TBIs) present with symptoms ranging from a mildly altered level of consciousness to irreversible coma and death. The most severe stage of TBIs is diffuse axonal injury and swelling affecting the whole brain. Management strategies are based on the classification of TBIs by severity and type and range from cognitive therapy sessions to complex surgeries. Neuroimaging modalities, predominantly magnetic resonance imaging, and the clinical Glasgow Coma Scale are principal indicators to diagnose and assess a patient's condition and neurological status and decide optimal treatment modality. In this review, we have summarized the indications and patient outcomes based on neurological and functional status, post-surgical complications, and mortality rates for various life-saving interventional procedures including surgery for brain contusions, intracranial hematomas and penetrating injuries, and craniectomy and ventriculostomy for elevated intracranial pressure and hydrocephalus. Cranioplasty performed for aesthetic purposes has also been explored. Overall quality evidence presented advocates surgery as needed for improved patient outcomes resulting in early recovery and decreased mortality, especially with the emergence of minimally invasive techniques. However, there is still an increased risk of certain complications like infections and bleeding and severe disabilities leading to a vegetative state with surgery. Some guidelines have been formed to provide indications for optimal management of TBI patients including surgeries, although their effectiveness in each individual case is debatable. It is imperative to explore certain key areas like the timing of the surgery and the role of intensive patient monitoring pre- and post-procedure in future studies and lay down guidelines also applicable to resource-limited areas. Also, a deeper understanding of physiological and pathological mechanisms of functional outcomes post-surgery will help clinicians predict the patient's course of recovery.
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Affiliation(s)
| | - Nagma Sabu
- Surgery, Jonelta Foundation School of Medicine University of Perpetual Help System DALTA, Las Pinas City, PHL
| | - Seetha Lakshmy
- Internal Medicine, Amala Institute of Medical Sciences, Thrissur, IND
| | | | | | | | - Aarushi Gupta
- Medicine, Avalon University School of Medicine, Youngstown, USA
| | | | - Jean C Daher
- Medicine, Lakeland Regional Health, Lakeland, USA
- Medicine, Universidad de Ciencias Medicas, San Jose, CRI
| | | | - Tanvi Mahajan
- Internal Medicine, Maharishi Markandeshwar Medical College and Hospital, Solan, IND
| | - Humza F Siddiqui
- Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
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21
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Andersson AS, Hossain I, Marklund N. Contusion expansion, low platelet count and bifrontal contusions are associated with worse patient outcome following traumatic brain injury-a retrospective single-center study. Acta Neurochir (Wien) 2024; 166:377. [PMID: 39316131 PMCID: PMC11422287 DOI: 10.1007/s00701-024-06269-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 09/09/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND Cortical contusions are common in moderate-severe traumatic brain injury (TBI). Cortical contusions often expand, potentially causing neuro-worsening several hours to days post-trauma. While contusion expansion (CE) may affect outcome, potential clinical and radiological markers that can predict CE have been insufficiently explored. In the present single-center retrospective observational cohort study, we evaluated clinical outcome by the Glasgow Outcome Scale extended (GOSE) scale and evaluated risk factor for CE. METHOD Adult TBI patients > 18 years of age, and of all injury severities, were included. Main variables of interest were low platelet count, defined as < 150 × 109/L, presence of bifrontal contusions and CE, defined as absolute contusion volume increase in cm3. Factors associated with CE and clinical outcome according to GOSE were analyzed. RESULTS Between 2012-2022, 272 patients were included. Contusion size on admission correlated positively with CE, as did the Marshall and Rotterdam radiological classification scores. Bifrontal contusions were significantly larger at admission, experienced larger CE, and had a worse outcome than contusions in other locations. Patients with a platelet count < 150 × 109/L experienced a greater volume CE and had a worse outcome when compared to patients with a normal platelet count. In a multivariate analysis, CE remained significantly associated with a poor outcome six months post- injury. CONCLUSION Contusion volume at admission, Marshall CT classification and Rotterdam CT score, positively correlated to CE. Bifrontal contusions and a platelet count < 150 × 109/L were associated with CE, and a poor clinical outcome. Large CE volumes were associated with a worse clinical outcome, and CE was per se associated with outcome in a multivariate analysis. Management of these risk factors for CE in the acute post-injury setting may be needed to attenuate contusion expansion and to improve clinical outcome in TBI patients suffering from cortical contusion injuries.
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Affiliation(s)
- Alice S Andersson
- Department of Clinical Sciences Lund, Neurosurgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Iftakher Hossain
- Department of Neurosurgery, Neurocenter, Turku University Hospital and University of Turku, Turku, Finland
- Department of Clinical Neurosciences, Division of Academic Neurosurgery Unit, Addenbrooke's Hospital and, University of Cambridge, Cambridge, UK
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University and Skane University Hospital, Lund, Sweden.
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22
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Zoerle T, Beqiri E, Åkerlund CAI, Gao G, Heldt T, Hawryluk GWJ, Stocchetti N. Intracranial pressure monitoring in adult patients with traumatic brain injury: challenges and innovations. Lancet Neurol 2024; 23:938-950. [PMID: 39152029 DOI: 10.1016/s1474-4422(24)00235-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 05/15/2024] [Accepted: 05/28/2024] [Indexed: 08/19/2024]
Abstract
Intracranial pressure monitoring enables the detection and treatment of intracranial hypertension, a potentially lethal insult after traumatic brain injury. Despite its widespread use, robust evidence supporting intracranial pressure monitoring and treatment remains sparse. International studies have shown large variations between centres regarding the indications for intracranial pressure monitoring and treatment of intracranial hypertension. Experts have reviewed these two aspects and, by consensus, provided practical approaches for monitoring and treatment. Advances have occurred in methods for non-invasive estimation of intracranial pressure although, for now, a reliable way to non-invasively and continuously measure intracranial pressure remains aspirational. Analysis of the intracranial pressure signal can provide information on brain compliance (ie, the ability of the cranium to tolerate volume changes) and on cerebral autoregulation (ie, the ability of cerebral blood vessels to react to changes in blood pressure). The information derived from the intracranial pressure signal might allow for more individualised patient management. Machine learning and artificial intelligence approaches are being increasingly applied to intracranial pressure monitoring, but many obstacles need to be overcome before their use in clinical practice could be attempted. Robust clinical trials are needed to support indications for intracranial pressure monitoring and treatment. Progress in non-invasive assessment of intracranial pressure and in signal analysis (for targeted treatment) will also be crucial.
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Affiliation(s)
- Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Guoyi Gao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thomas Heldt
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Gregory W J Hawryluk
- Cleveland Clinic Akron General Hospital, Uniformed Services University, Cleveland, OH, USA
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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23
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Jirlow U, Hossain I, Korhonen O, Depreitere B, Rostami E. Cerebral contusions - Pathomechanism, predictive factors for progression and historical and current management. BRAIN & SPINE 2024; 4:103329. [PMID: 39281852 PMCID: PMC11402187 DOI: 10.1016/j.bas.2024.103329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/19/2024] [Accepted: 08/27/2024] [Indexed: 09/18/2024]
Abstract
Introduction Cerebral contusions (CCs) are common traumatic brain injuries known for their propensity to progress. Understanding their mechanical pathogenesis and predictive factors for progression is crucial for optimal management. Research question To provide an overview of current knowledge on CCs, including pathomechanisms, predictive factors of contusion progression, and management strategies. Material and methods A literature search was conducted using PubMed, Scopus and ISI web of knowledge focused on articles in English with the words "cerebral contusion" together with the words "traumatic brain injury", "pathomechanism", "progression of contusion", "predictive factors" and "management" alone or in combination. Results The management of CCs has evolved alongside the advances in neurointensive care, yet there is no consensus. Evidence on the effectiveness of early surgery, importantly, for the group which has the potential to expand, is limited. Some predictive factors for contusion progression have been identified, including age, injury mechanism, coagulopathy and initial contusion volume which could help to guide decision-making. Discussion and conclusion While various theories exist on pathomechanisms and several predictive factors for progression have been proposed, consensus on optimal management remains elusive. Individualized care guided by the predictive factors is essential. Challenges posed by antithrombotic medications highlight the need for early intervention strategies.Decompressive craniectomy could serve as a potential tool in severe traumatic brain injury management including contusions. Conducting large cohort studies to refine predictive models and harmonizing management approaches would help to improve outcomes of patients with CCs.
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Affiliation(s)
- Unni Jirlow
- Department of Medical sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Iftakher Hossain
- Neurocentre, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Otto Korhonen
- Neurocentre, Department of Neurosurgery, Turku University Hospital, Turku, Finland
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Elham Rostami
- Department of Medical sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
- Department of Neuroscience, Karolinska Institute, Sweden
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24
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Gkantsinikoudis N, Hossain I, Marklund N, Tsitsopoulos PP. Neurosurgical intervention in ultra-severe closed traumatic brain injury: Is it worth the effort? BRAIN & SPINE 2024; 4:102907. [PMID: 39262578 PMCID: PMC11388290 DOI: 10.1016/j.bas.2024.102907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/28/2024] [Accepted: 08/05/2024] [Indexed: 09/13/2024]
Abstract
Introduction A subgroup of severe Traumatic Brain Injury (TBI) patients, known as ultra-severe (us-TBI), is most commonly defined as a post-resuscitation Glasgow Coma Scale (GCS) of 3-5. There is uncertainty on whether these critically injured patients can benefit from neurosurgical intervention. Research question The available evidence regarding the decision-making and outcome following management of us-TBI patients is critically reviewed. Material and methods Selected databases (PubMed, Google Scholar, Scopus and Cochrane Library) were searched from 1979 to May 2024 for publications on us-TBI patients, with a focus on treatment strategy, mortality and functional outcomes. Inclusion criteria were adult patients >18 years old with closed head trauma and admission post-resuscitation GCS 3-5. Studies were independently assessed for inclusion by two reviewers, and potential disagreements were solved by consensus. Results Where such data could be extracted, mortality rate was 27-100%, and favorable outcome was observed in 4-30% of us-TBI patients. While early aggressive neurosurgical management was associated with decreased mortality, a high proportion of patients survived with unfavorable functional status. Discussion and conclusion With supportive care only, outcome of patients with us-TBI is almost universally poor. Early and aggressive neurosurgical intervention in addition to best medical management can lead to favorable functional outcome in selected cases particularly in younger patients with an initial GCS>3 and traumatic mass lesions. There is insufficient data regarding the effectiveness of neurosurgical management on the outcome of us-TBI patients. and the decision to initiate treatment should be based on an individual basis.
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Affiliation(s)
- Nikolaos Gkantsinikoudis
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloniki, Greece
| | - Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, and Skåne University Hospital Lund, Sweden
| | - Parmenion P Tsitsopoulos
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloniki, Greece
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25
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Brindley PG, Sanderson M, Anderson D, O’Kelly C. Decompressive craniectomy: A primer for acute care practitioners. J Intensive Care Soc 2024; 25:339-345. [PMID: 39224422 PMCID: PMC11366190 DOI: 10.1177/17511437241237760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Decompressive craniectomy (DC) involves surgical removal of the skull that overlies swollen, imperiled, brain. This is done to combat intracranial hypertension and mitigate a vicious cycle of secondary brain injury. If, instead, this pathophysiology goes uninterrupted, it can mean brain herniation and brain stem death. As such, DC can save lives when all else fails. Regardless, it is no panacea and can also "ruin deaths," and leave patients profoundly disabled. DC is not a new procedure; however, this therapy is increasingly noteworthy due to advances in neurocritical care, alongside ethical concerns. We cover the physiological rationale, the surgical basics, the trial data, and focus on secondary decompression (for refractory intracranial pressure (ICP)) rather than primary decompression (i.e. during evacuation of an intracranial mass). Given that DC should not be undertaken indiscriminately, we conclude by introducing ways in which to discuss DC with families and colleagues. Our goal is to provide a primer and common resource for the multidisciplinary team. We aim to increase not only knowledge but wisdom, prudence, collegiality, and family-focused care.
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Affiliation(s)
| | - Mark Sanderson
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Dustin Anderson
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Cian O’Kelly
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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26
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Singh C, Gharde P, Iratwar S, Verma P, Triwedi B. Decompressive Craniectomy: From Ancient Practices to Modern Neurosurgery. Cureus 2024; 16:e64923. [PMID: 39156316 PMCID: PMC11330637 DOI: 10.7759/cureus.64923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/19/2024] [Indexed: 08/20/2024] Open
Abstract
Decompressive craniectomy (DC) is a neurosurgical strategy that expels a parcel of the cranium to relieve pressure on a swollen or herniating brain. This review article explores the history of DC, from its ancient roots in trepanning to its contemporary applications. It then examines the mechanisms by which DC reduces intracranial pressure (ICP) and improves cerebral blood flow. The article highlights the efficacy of DC in treating patients with severe traumatic brain injury (TBI), stroke, and other conditions that cause increased ICP. However, it also acknowledges the potential complications of DC, such as infection and bleeding. The ethical considerations surrounding DC are explored in detail, particularly the challenging decision-making process for patients who are unable to give consent. A specific focus is given to the use of DC in pediatric patients, where the developing brain is especially vulnerable to pressure changes.
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Affiliation(s)
- Chahat Singh
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Gharde
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sandeep Iratwar
- Neurosurgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Prince Verma
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Bhushan Triwedi
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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27
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Bath MF, Hobbs L, Kohler K, Kuhn I, Nabulyato W, Kwizera A, Walker LE, Wilkins T, Stubbs D, Burnstein RM, Kolias A, Hutchinson PJ, Clarkson PJ, Halimah S, Bashford T. Does the implementation of a trauma system affect injury-related morbidity and economic outcomes? A systematic review. Emerg Med J 2024; 41:409-414. [PMID: 38388191 PMCID: PMC11228185 DOI: 10.1136/emermed-2023-213782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/10/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND Trauma accounts for a huge burden of disease worldwide. Trauma systems have been implemented in multiple countries across the globe, aiming to link and optimise multiple aspects of the trauma care pathway, and while they have been shown to reduce overall mortality, much less is known about their cost-effectiveness and impact on morbidity. METHODS We performed a systematic review to explore the impact the implementation of a trauma system has on morbidity, quality of life and economic outcomes, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All comparator study types published since 2000 were included, both retrospective and prospective in nature, and no limits were placed on language. Data were reported as a narrative review. RESULTS Seven articles were identified that met the inclusion criteria, all of which reported a pre-trauma and post-trauma system implementation comparison in high-income settings. The overall study quality was poor, with all studies demonstrating a severe risk of bias. Five studies reported across multiple types of trauma patients, the majority describing a positive impact across a variety of morbidity and health economic outcomes following trauma system implementation. Two studies focused specifically on traumatic brain injury and did not demonstrate any impact on morbidity outcomes. DISCUSSION There is currently limited and poor quality evidence that assesses the impact that trauma systems have on morbidity, quality of life and economic outcomes. While trauma systems have a fundamental role to play in high-quality trauma care, morbidity and disability data can have large economic and cultural consequences, even if mortality rates have improved. The sociocultural and political context of the surrounding healthcare infrastructure must be better understood before implementing any trauma system, particularly in resource-poor and fragile settings. PROSPERO REGISTRATION NUMBER CRD42022348529 LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Michael F Bath
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
- NIHR Global Health Research Group on Acquired Brain and Spine Injury, Division of Academic Neurosurgery, University of Cambridge, Cambridge, UK
| | - Laura Hobbs
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
- NIHR Global Health Research Group on Acquired Brain and Spine Injury, Division of Academic Neurosurgery, University of Cambridge, Cambridge, UK
- Department of Anaesthesia, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Katharina Kohler
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
- NIHR Global Health Research Group on Acquired Brain and Spine Injury, Division of Academic Neurosurgery, University of Cambridge, Cambridge, UK
- Department of Perioperative, Acute, Critical Care, and Emergency Medicine, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Isla Kuhn
- University of Cambridge Medical Library, University of Cambridge, Cambridge, UK
| | - William Nabulyato
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
| | - Arthur Kwizera
- Department of Anaesthesia and Intensive Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Laura E Walker
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tom Wilkins
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Daniel Stubbs
- Department of Perioperative, Acute, Critical Care, and Emergency Medicine, Department of Medicine, University of Cambridge, Cambridge, UK
| | - R M Burnstein
- Department of Perioperative, Acute, Critical Care, and Emergency Medicine, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Angelos Kolias
- NIHR Global Health Research Group on Acquired Brain and Spine Injury, Division of Academic Neurosurgery, University of Cambridge, Cambridge, UK
| | - Peter John Hutchinson
- NIHR Global Health Research Group on Acquired Brain and Spine Injury, Division of Academic Neurosurgery, University of Cambridge, Cambridge, UK
| | - P John Clarkson
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
- Cambridge Public Health Interdisciplinary Research Centre, University of Cambridge, Cambridge, UK
| | - Sara Halimah
- Trauma Operational Advisory Team, World Health Organization, Cairo, Egypt
| | - Tom Bashford
- International Health Systems Group, Department of Engineering, University of Cambridge, Cambridge, UK
- NIHR Global Health Research Group on Acquired Brain and Spine Injury, Division of Academic Neurosurgery, University of Cambridge, Cambridge, UK
- Department of Perioperative, Acute, Critical Care, and Emergency Medicine, Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Public Health Interdisciplinary Research Centre, University of Cambridge, Cambridge, UK
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Keeves J, Gadowski A, McKimmie A, Bagg MK, Antonic-Baker A, Hicks AJ, Clarke N, Brown A, McNamara R, Reeder S, Roman C, Jeffcote T, Romero L, Hill R, Ponsford JL, Lannin NA, O'Brien TJ, Cameron PA, Rushworth N, Fitzgerald M, Gabbe BJ, Cooper DJ. The Australian Traumatic Brain Injury Initiative: Systematic Review of the Effect of Acute Interventions on Outcome for People With Moderate-Severe Traumatic Brain Injury. J Neurotrauma 2024. [PMID: 38279797 DOI: 10.1089/neu.2023.0465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
The Australian Traumatic Brain Injury Initiative (AUS-TBI) is developing a data resource to enable improved outcome prediction for people with moderate-severe TBI (msTBI) across Australia. Fundamental to this resource is the collaboratively designed data dictionary. This systematic review and consultation aimed to identify acute interventions with potential to modify clinical outcomes for people after msTBI, for inclusion in a data dictionary. Standardized searches were implemented across bibliographic databases from inception through April 2022. English-language reports of randomized controlled trials (RCTs) evaluating any association between any acute intervention and clinical outcome in at least 100 patients with msTBI, were included. A predefined algorithm was used to assign a value to each observed association. Consultation with AUS-TBI clinicians and researchers formed the consensus process for interventions to be included in a single data dictionary. Searches retrieved 14,455 records, of which 124 full-length RCTs were screened, with 35 studies included. These studies evaluated 26 unique acute interventions across 21 unique clinical outcomes. Only 4 interventions were considered to have medium modifying value for any outcome from the review, with an additional 8 interventions agreed upon through the consensus process. The interventions with medium value were tranexamic acid and phenytoin, which had a positive effect on an outcome; and decompressive craniectomy surgery and hypothermia, which negatively affected outcomes. From the systematic review and consensus process, 12 interventions were identified as potential modifiers to be included in the AUS-TBI national data resource.
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Affiliation(s)
- Jemma Keeves
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adelle Gadowski
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ancelin McKimmie
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Matthew K Bagg
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health Sciences and Physiotherapy, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Ana Antonic-Baker
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nyssa Clarke
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alastair Brown
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Rob McNamara
- School of Medicine, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sandy Reeder
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Toby Jeffcote
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | | | - Regina Hill
- Regina Hill Effective Consulting Pty. Ltd., Melbourne, Victoria, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
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Suryavanshi P, Langton R, Fairhead K, Glykys J. Brief and diverse excitotoxic insults cause an increase in neuronal nuclear membrane permeability in the neonatal brain. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.08.22.554167. [PMID: 37662276 PMCID: PMC10473591 DOI: 10.1101/2023.08.22.554167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Neuronal swelling after excitotoxic insults is implicated in neuronal injury and death in the developing brain, yet mitigating brain edema with osmotic and surgical interventions yields poor clinical outcomes. Importantly, neuronal swelling and its downstream consequences during early brain development remain poorly investigated. Using multiphoton Ca2+ imaging in vivo (P12-17) and in acute brain slices (P8-12), we explored Ca2+-dependent downstream effects after neuronal cytotoxic edema. We observed the translocation of cytosolic GCaMP6s into the nucleus of a subpopulation of neurons minutes after various excitotoxic insults. We used automated morphology-detection algorithms for neuronal segmentation and quantified the nuclear translocation of GCaMP6s as the ratio of nuclear and cytosolic intensity (N/C ratio). Elevated neuronal N/C ratios were correlated to higher Ca2+ loads and could occur independently of neuronal swelling. Electron microscopy revealed that the nuclear translocation was associated with increased nuclear pore size. Inhibiting calpains prevented elevated N/C ratios and neuronal swelling. Thus, our results indicate altered nuclear transport in a subpopulation of neurons shortly after injury in the developing brain, which can be used as an early biomarker of acute neuronal injury.
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Affiliation(s)
- P Suryavanshi
- Department of Pediatrics, University of Iowa, Iowa City, IA
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA
| | - R Langton
- Department of Pediatrics, University of Iowa, Iowa City, IA
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA
| | - K Fairhead
- Biomedical Sciences, College of Liberal Arts and Sciences, University of Iowa, Iowa City, IA
| | - J Glykys
- Department of Pediatrics, University of Iowa, Iowa City, IA
- Iowa Neuroscience Institute, University of Iowa, Iowa City, IA
- Department of Neurology, University of Iowa, Iowa City, IA
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Caceres E, Divani AA, Rubinos CA, Olivella-Gómez J, Viñán-Garcés AE, González A, Alvarado-Arias A, Bathia K, Samadani U, Reyes LF. PaCO2 Association with Traumatic Brain Injury Patients Outcomes at High Altitude: A Prospective Single-Center Cohort Study. RESEARCH SQUARE 2024:rs.3.rs-3876988. [PMID: 38343855 PMCID: PMC10854293 DOI: 10.21203/rs.3.rs-3876988/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Background partial pressure of carbon dioxide (PaCO2) is generally known to influence outcome in patients with traumatic brain injury (TBI) at normal altitudes. Less is known about specific relationships of PaCO2 levels and clinical outcomes at high altitudes. Methods This is a prospective single-center cohort of consecutive TBI patients admitted to a trauma center located at 2600 meter above sea level. An unfavorable outcome was defined as the Glasgow Outcome Scale-Extended (GOSE) < 4 at 6-month follow-up. Results 81 patients with complete data, 80% (65/81) were men, and median (IQR) age was 36 (25-50) years). Median Glasgow Coma Scale (GCS) on admission was 9 (6-14), 49% (40/81) were severe (GCS: 3-8), 32% (26/81) moderate (GCS 12 - 9), and 18% (15/81) mild (GCS 13-15) TBI. The median (IQR) Abbreviated Injury Score of the Head (AISh) was 3 (2-4). Frequency of an unfavorable outcome (GOSE < 4) was 30% (25/81), median GOSE was 4 (2-5), and 6-month mortality was 24% (20/81). Comparison between patients with favorable and unfavorable outcomes revealed that those with unfavorable outcome were older, median [49 (30-72) vs. 29 (22-41), P < 0.01], had lower admission GCS [6 (4-8) vs. 13 (8-15), P < 0.01], higher AIS head [4 (4-4) vs. 3(2-4), p < 0.01], higher APACHE II score [17(15-23) vs 10 (6-14), < 0.01), higher Charlson score [0(0-2) vs. 0 (0-0), P < 0.01] and higher PaCO2 (mmHg), mean ± SD, 39 ± 9 vs. 32 ± 6, P < 0.01. In a multivariate analysis, age (OR 1.14 95% CI 1.1-1.30, P < 0.01), AISh (OR 4.7 95% CI 1.55-21.0, P < 0.05), and PaCO2 (OR 1.23 95% CI: 1.10-1.53, P < 0.05) were significantly associated with the unfavorable outcomes. When applying the same analysis to the subgroup on mechanical ventilation, AISh (OR 5.4 95% CI: 1.61-28.5, P = 0.017) and PaCO2 (OR 1.36 95% CI: 1.13-1.78, P = 0.015) remained significantly associated with the unfavorable outcome. Conclusion Higher PaCO2 levels are associated with an unfavorable outcome in ventilated TBI patients. These results underscore the importance of PaCO2 level in TBI patients and whether it should be adjusted for populations living at higher altitudes.
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Affiliation(s)
| | - Afshin A Divani
- University of New Mexico - Albuquerque: The University of New Mexico
| | - Clio A Rubinos
- University of North Carolina at Chapel Hill Health Sciences Library: The University of North Carolina at Chapel Hill
| | | | | | | | - Alexis Alvarado-Arias
- University of Mississippi University Hospital: The University of Mississippi Medical Center
| | - Kunal Bathia
- University of Mississippi University Hospital: The University of Mississippi Medical Center
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Stansbury BM, Kelley CJ, Rudy RF, Bonnin SS, Chapple KM, Snyder LA, Weinberg JA, Huang DD. Pentobarbital coma for management of intracranial hypertension following traumatic brain injury: Lack of early response to treatment portends poor outcomes. Am J Surg 2023; 226:864-867. [PMID: 37532593 DOI: 10.1016/j.amjsurg.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) results in the death of over 50,000 and the permanent disability of 80,000 individuals annually in the United States. Much of the permanent disability is the result of secondary brain injury from intracranial hypertension (ICH). Pentobarbital coma is often instituted following the failure of osmotic interventions and sedation to control intracranial pressure (ICP). The goal of this study was to evaluate the efficacy of pentobarbital coma with respect to ICP management and long-term functional outcome. METHODS Traumatic brain injury patients who underwent pentobarbital coma at a level 1 trauma center between 2014 and 2021 were identified. Patient demographics, injury characteristics, Glasgow Coma Scale (GCS) scores, intracranial pressures (ICPs), and outcomes were obtained from the trauma registry as well as inpatient and outpatient medical records. The proportion of ICPs below 20 for each hospitalized patient-day was calculated. The primary outcome measured was GCS score at the last follow-up visit. RESULTS 25 patients were identified, and the majority were male (n = 23, 92%) with an average age of 30.0 years ± 12.9 and median injury severity score of 30 (21.5-33.5). ICPs were monitored for all patients with a median of 464 (326-1034) measurements. The average hospital stay was 16.9 days ± 11.5 and intensive care stay was 16.9 ± 10.8 days. 9 (36.0%) patients survived to hospital discharge. Mean follow-up time in months was 36.9 ± 28.0 (min-max 3-80). 7 of the 9 surviving patients presented as GCS 15 on follow-up and the remaining were both GCS 9. Patients presenting at last follow-up with GCS 15 had a significantly higher proportion of controlled ICPs throughout their hospitalization compared to patients who expired or with follow-up GCS <15 (GCS 15: 88% ± 10% vs. GCS <15 or dead: 68% ± 22%, P = 0.006). A comparison of the daily proportion of controlled ICPs by group revealed negligible differences prior to pentobarbital initiation. Groups diverged nearly immediately upon pentobarbital coma initiation with a higher proportion of controlled ICPs for patients with follow-up GCS of 15. CONCLUSION Patients that do not have an immediate response to pentobarbital coma therapy for ICH universally had poor outcomes. Alternative therapy or earlier palliation should be considered for such patients. In contrast, patients whose ICPs responded quickly to pentobarbital had excellent long-term outcomes.
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Affiliation(s)
- Brittany M Stansbury
- Creighton University School of Medicine Phoenix Regional Campus, St. Joseph's Hospital and Medical Center, 350 West Thomas Rd. Phoenix, AZ 85013, USA.
| | - Caitlin J Kelley
- Creighton University School of Medicine Phoenix Regional Campus, St. Joseph's Hospital and Medical Center, 350 West Thomas Rd. Phoenix, AZ 85013, USA.
| | - Robert F Rudy
- Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ 85013, USA.
| | - Sophia S Bonnin
- St. Joseph's Hospital and Medical Center Pharmacy Department, 350 West Thomas Rd. Phoenix, AZ 85013, USA.
| | - Kristina M Chapple
- Creighton University School of Medicine Phoenix Regional Campus, St. Joseph's Hospital and Medical Center, 350 West Thomas Rd. Phoenix, AZ 85013, USA.
| | - Laura A Snyder
- Barrow Neurological Institute, 2910 North Third Avenue, Phoenix, AZ 85013, USA.
| | - Jordan A Weinberg
- Creighton University School of Medicine Phoenix Regional Campus, St. Joseph's Hospital and Medical Center, 350 West Thomas Rd. Phoenix, AZ 85013, USA.
| | - Dih-Dih Huang
- Creighton University School of Medicine Phoenix Regional Campus, St. Joseph's Hospital and Medical Center, 350 West Thomas Rd. Phoenix, AZ 85013, USA.
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Kamabu LK, Oboth R, Bbosa G, Baptist SJ, Kaddumukasa MN, Deng D, Lekuya HM, Kataka LM, Kiryabwire J, Moses G, Sajatovic M, Kaddumukasa M, Fuller AT. Predictive models for occurrence of expansive intracranial hematomas and surgical evacuation outcomes in traumatic brain injury patients in Uganda: A prospective cohort study. RESEARCH SQUARE 2023:rs.3.rs-3626631. [PMID: 38045250 PMCID: PMC10690308 DOI: 10.21203/rs.3.rs-3626631/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
BACKGROUND Hematoma expansion is a common manifestation of acute intracranial hemorrhage (ICH) which is associated with poor outcomes and functional status. Objective We determined the prevalence of expansive intracranial hematomas (EIH) and assessed the predictive model for EIH occurrence and surgical evacuation outcomes in patients with traumatic brain injury (TBI) in Uganda. Methods We recruited adult patients with TBI with intracranial hematomas in a prospective cohort study. Data analysis using logistic regression to identify relevant risk factors, assess the interactions between variables, and developing a predictive model for EIH occurrence and surgical evacuation outcomes in TBI patients was performed. The predictive accuracies of these algorithms were compared using the area under the receiver operating characteristic curve (AUC). A p-values of < 0.05 at a 95% Confidence interval (CI) was considered significant. Results A total of 324 study participants with intracranial hemorrhage were followed up for 6 months after surgery. About 59.3% (192/324) had expansive intracranial hemorrhage. The study participants with expansive intracranial hemorrhage had poor quality of life at both 3 and 6-months with p < 0.010 respectively. Among the 5 machine learning algorithms, the random forest performed the best in predicting EIH in both the training cohort (AUC = 0.833) and the validation cohort (AUC = 0.734). The top five features in the random forest algorithm-based model were subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma. Other models demonstrated good discrimination with AUC for intraoperative complication (0.675) and poor discrimination for mortality (0.366) after neurosurgical evacuation in TBI patients. Conclusion Expansive intracranial hemorrhage is common among patients with traumatic brain injury in Uganda. Early identification of patients with subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma, were crucial in predicting EIH and intraoperative complications.
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Zhang Q, Li Y, Chang X. Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury - A Meta-Analysis of Randomized Controlled Trials. Ann Indian Acad Neurol 2023; 26:966-974. [PMID: 38229611 PMCID: PMC10789412 DOI: 10.4103/aian.aian_432_23] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/26/2023] [Accepted: 07/15/2023] [Indexed: 01/18/2024] Open
Abstract
Background Traumatic brain injury (TBI) is a serious medical condition that often leads to significant morbidity and mortality. Decompressive craniectomy (DC) is now widely recognized as a primary or secondary treatment option for managing intracranial pressure (ICP) in patients with severe TBI. However, there is a lack of clarity in reviews regarding the impact of DC on TBI outcomes. Objectives The aim of this study is to evaluate the effectiveness of DC in terms of overall mortality and long-term prognosis among patients with TBI. Materials and Methods We conducted a systematic search of four common databases to include all parallel-arm randomized controlled trials (RCTs). We selected studies that reported outcomes for TBI cases, with DC as a treatment option. The outcomes examined included reduction in mortality, ICP levels, and the proportion of patients with a Glasgow Outcome Scale score >4. Results Our review finally included eight RCTs [n = 1458, with 749 and 709 patients in the DC and control groups, respectively]. The weighted mean difference for ICP was estimated at -4.01 (95% Confidence interval [CI]: -5.31--2.71), indicating a statistically significant reduction in ICP levels in the DC group compared to the control group. The pooled risk ratio was 0.67 (95% CI: 0.51-0.89), suggesting a statistically significant 31% decrease in mortality levels in the DC group. Subgroup and sensitivity analyzes were also conducted to address heterogeneity. Discussion and Conclusion In conclusion, based on our meta-analysis, we find that DC can be considered a crucial surgical intervention for reducing mortality among patients with TBI when compared to control groups.
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Affiliation(s)
- Qiang Zhang
- Department of Neurosurgery, The 961 Hospital of the Chinese People's Liberation Army Joint Logistic Support Force, No. 71 Postal Road, Qiqihar 161000, Heilongjiang
| | - Yuhuan Li
- Department of Neurosurgery, Beijing Crops Hospital of Chinese People Armed Police Forces, Beijing
| | - Xiaozan Chang
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
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Mendelow AD. The diversity of skills that are needed in different environments. Front Surg 2023; 10:1240154. [PMID: 37799116 PMCID: PMC10548258 DOI: 10.3389/fsurg.2023.1240154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/08/2023] [Indexed: 10/07/2023] Open
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Alduais A, Trivkovic T, Allegretta S, Alfadda H. Neuropragmatics: A scientometric review. APPLIED NEUROPSYCHOLOGY. ADULT 2023:1-31. [PMID: 37708841 DOI: 10.1080/23279095.2023.2251634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Neuropragmatics investigates brain functions and neural activities responsible for pragmatic language abilities, often impaired in disorders such as hemisphere damage, autism, schizophrenia, and neurodegenerative disorders. This study examined the development of neuropragmatics and existing neuroimaging evidence using bibliometric and scientometric indicators, analyzing 4,247 documents published between 1967 and 2022 with CiteSpace and VOSviewer. Our cluster analysis revealed key themes. 1) Language comprehension loss due to brain injury: Studies exploring the impact of brain injuries on language comprehension and underlying neural mechanisms. 2) Right hemisphere damage and pragmatic language skills: Research focusing on the relationship between right hemisphere damage and pragmatic language abilities, investigating impairments in social language use and potential neural correlates. 3) Traumatic brain injury and social communication assessment: Research on traumatic brain injury effects on social communication skills, using various assessment tools to evaluate communication effectiveness in social situations. These clusters provide valuable insights into the neuropragmatics field and serve as a framework for future investigations. By building upon existing knowledge, researchers can improve our understanding of brain functions, language behavior, and enhance rehabilitation for individuals with pragmatic language impairments.
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Affiliation(s)
- Ahmed Alduais
- Department of Human Sciences (Psychology), University of Verona, Verona, Italy
| | - Tamara Trivkovic
- Department of Speech and Language Pathology, College of Social Work, Belgrade, Serbia
| | | | - Hind Alfadda
- Department of Curriculum and Instruction, King Saud University, Riyadh, Saudi Arabia
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Björk S, Hånell A, Ronne-Engström E, Stenwall A, Velle F, Lewén A, Enblad P, Svedung Wettervik T. Thiopental and decompressive craniectomy as last-tier ICP-treatments in aneurysmal subarachnoid hemorrhage: is functional recovery within reach? Neurosurg Rev 2023; 46:231. [PMID: 37676578 PMCID: PMC10485091 DOI: 10.1007/s10143-023-02138-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/17/2023] [Accepted: 09/01/2023] [Indexed: 09/08/2023]
Abstract
The study aimed to investigate the indication and functional outcome after barbiturates and decompressive craniectomy (DC) as last-tier treatments for elevated intracranial pressure (ICP) in aneurysmal subarachnoid hemorrhage (aSAH). This observational study included 891 aSAH patients treated at a single center between 2008 and 2018. Data on demography, admission status, radiology, ICP, clinical course, and outcome 1-year post-ictus were collected. Patients treated with thiopental (barbiturate) and DC were the main target group.Thirty-nine patients (4%) were treated with thiopental alone and 52 (6%) with DC. These patients were younger and had a worse neurological status than those who did not require these treatments. Before thiopental, the median midline shift was 0 mm, whereas basal cisterns were compressed/obliterated in 66%. The median percentage of monitoring time with ICP > 20 mmHg immediately before treatment was 38%, which did not improve after 6 h of infusion. Before DC, the median midline shift was 10 mm, and the median percentage of monitoring time with ICP > 20 mmHg before DC was 56%, which both significantly improved postoperatively. At follow-up, 52% of the patients not given thiopental or operated with DC reached favorable outcome, whereas this occurred in 10% of the thiopental and DC patients.In summary, 10% of the aSAH cohort required thiopental, DC, or both. Thiopental and DC are important integrated last-tier treatment options, but careful patient selection is needed due to the risk of saving many patients into a state of suffering.
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Affiliation(s)
- Sofie Björk
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anton Stenwall
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Fartein Velle
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
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Decraene B, Klein SP, Piper I, Gregson B, Enblad P, Ragauskas A, Citerio G, Chambers I, Neumann JO, Sahuquillo J, Kiening K, Moss L, Nilsson P, Donald R, Howells T, Lo M, Depreitere B. Decompressive craniectomy as a second/third-tier intervention in traumatic brain injury: A multicenter observational study. Injury 2023; 54:110911. [PMID: 37365094 DOI: 10.1016/j.injury.2023.110911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES RESCUEicp studied decompressive craniectomy (DC) applied as third-tier option in severe traumatic brain injury (TBI) patients in a randomized controlled setting and demonstrated a decrease in mortality with similar rates of favorable outcome in the DC group compared to the medical management group. In many centers, DC is being used in combination with other second/third-tier therapies. The aim of the present study is to investigate outcomes from DC in a prospective non-RCT context. METHODS This is a prospective observational study of 2 patient cohorts: one from the University Hospitals Leuven (2008-2016) and one from the Brain-IT study, a European multicenter database (2003-2005). In thirty-seven patients with refractory elevated intracranial pressure who underwent DC as a second/third-tier intervention, patient, injury and management variables including physiological monitoring data and administration of thiopental were analysed, as well as Extended Glasgow Outcome score (GOSE) at 6 months. RESULTS In the current cohorts, patients were older than in the surgical RESCUEicp cohort (mean 39.6 vs. 32.3; p < 0.001), had higher Glasgow Motor Score on admission (GMS < 3 in 24.3% vs. 53.0%; p = 0.003) and 37.8% received thiopental (vs. 9.4%; p < 0.001). Other variables were not significantly different. GOSE distribution was: death 24.3%; vegetative 2.7%; lower severe disability 10.8%; upper severe disability 13.5%; lower moderate disability 5.4%; upper moderate disability 2.7%, lower good recovery 35.1%; and upper good recovery 5.4%. The outcome was unfavorable in 51.4% and favorable in 48.6%, as opposed to 72.6% and 27.4% respectively in RESCUEicp (p = 0.02). CONCLUSION Outcomes in DC patients from two prospective cohorts reflecting everyday practice were better than in RESCUEicp surgical patients. Mortality was similar, but fewer patients remained vegetative or severely disabled and more patients had a good recovery. Although patients were older and injury severity was lower, a potential partial explanation may be in the pragmatic use of DC in combination with other second/third-tier therapies in real-life cohorts. The findings underscore that DC maintains an important role in managing severe TBI.
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Affiliation(s)
| | | | - Ian Piper
- Southern General Hospital, Glasgow, United Kingdom
| | | | | | | | | | - Iain Chambers
- James Cook University Hospital, Middlesbrough, United Kingdom
| | | | | | - Karl Kiening
- Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Laura Moss
- Southern General Hospital, Glasgow, United Kingdom
| | | | - Rob Donald
- Stats Research, Scotland, United Kingdom
| | | | - Milly Lo
- University of Edinburgh, Edinburgh, United Kingdom
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Carlhan-Ledermann A, Bartoli A, Gebistorf F, Beghetti M, Sologashvili T, Rebollo Polo M, Fluss J. Decompressive hemicraniectomy in pediatric malignant arterial ischemic stroke: a case-based review. Childs Nerv Syst 2023; 39:2377-2389. [PMID: 37493722 PMCID: PMC10432330 DOI: 10.1007/s00381-023-06086-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE Malignant stroke is a life-threatening emergency, with a high mortality rate (1-3). Despite strong evidence showing decreased morbidity and mortality in the adult population, decompressive hemicraniectomy (DCH) has been scarcely reported in the pediatric stroke population, and its indication remains controversial, while it could be a potential lifesaving option. METHODS AND RESULTS We performed an extensive literature review on pediatric malignant arterial ischemic stroke (pmAIS) and selected 26 articles reporting 97 cases. Gathering the data together, a 67% mortality rate is observed without decompressive therapy, contrasting with a 95.4% survival rate with it. The median modified Rankin score (mRS) is 2.1 after surgery with a mean follow-up of 31.8 months. For the 33% of children who survived without surgery, the mRS is 3 at a mean follow-up of 19 months. As an illustrative case, we report on a 2-year-old girl who presented a cardioembolic right middle cerebral artery stroke with subsequent malignant edema and ongoing cerebral transtentorial herniation in the course of a severe myocarditis requiring ECMO support. A DCH was done 32 h after symptom onset. At the age of 5 years, she exhibits an mRS of 3. CONCLUSION Pediatric stroke with malignant edema is a severe condition with high mortality rate if left untreated and often long-lasting consequences. DCH might minimize the vicious circle of cerebral swelling, increasing intracranial pressure and brain ischemia. Our literature review underscores DCH as an efficient therapeutic measure management of pmAIS even when performed after a significant delay; however, long-lasting morbidities remain high.
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Affiliation(s)
- Audrey Carlhan-Ledermann
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Andrea Bartoli
- Neurosurgery Unit, Department of Clinical Neuroscience, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Fabienne Gebistorf
- Neonatology and Pediatric Intensive Care Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Tornike Sologashvili
- Cardiovascular Surgery Unit, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Monica Rebollo Polo
- Pediatric Radiology Unit, Department of Radiology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Joel Fluss
- Pediatric Neurology Unit, Department of Woman, Child and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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van Essen TA, van Erp IA, Lingsma HF, Pisică D, Yue JK, Singh RD, van Dijck JT, Volovici V, Younsi A, Kolias A, Peppel LD, Heijenbrok-Kal M, Ribbers GM, Menon DK, Hutchinson PJ, Manley GT, Depreitere B, Steyerberg EW, Maas AI, de Ruiter GC, Peul WC. Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study. EClinicalMedicine 2023; 63:102161. [PMID: 37600483 PMCID: PMC10432786 DOI: 10.1016/j.eclinm.2023.102161] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023] Open
Abstract
Background Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. Methods We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Findings Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7-1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n = 200]). Interpretation We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Funding Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.
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Affiliation(s)
- Thomas A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- Department of Surgery, Division of Neurosurgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Inge A.M. van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Hester F. Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Dana Pisică
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - John K. Yue
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Ranjit D. Singh
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Jeroen T.J.M. van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Alexander Younsi
- Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Lianne D. Peppel
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Majanka Heijenbrok-Kal
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Gerard M. Ribbers
- Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J.A. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Geoffrey T. Manley
- Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
| | - Bart Depreitere
- Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Godard C.W. de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
| | - Wilco C. Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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Newcombe V, Muehlschlegel S, Sonneville R. Neurological diseases in intensive care. Intensive Care Med 2023; 49:987-990. [PMID: 37430156 DOI: 10.1007/s00134-023-07150-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/22/2023] [Indexed: 07/12/2023]
Affiliation(s)
- Virginia Newcombe
- University Division of Anaesthesia, PACE Section, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Box 93, Cambridge, CB2 OQQ, UK.
- Neurosciences and Trauma Critical Care Unit (NCCU), Addenbrooke's Hospital, Cambridge, UK.
- Emergency Department, Addenbrooke's Hospital, Cambridge, UK.
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Romain Sonneville
- Université Paris Cité, INSERM UMR1148, Team 6, 75018, Paris, France
- Department of Intensive Care Medicine, AP-HP, Hôpital Bichat-Claude Bernard, 75018, Paris, France
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Kim JH, Choo YH, Jeong H, Kim M, Ha EJ, Oh J, Lee S. Recent Updates on Controversies in Decompressive Craniectomy and Cranioplasty: Physiological Effect, Indication, Complication, and Management. Korean J Neurotrauma 2023; 19:128-148. [PMID: 37431371 PMCID: PMC10329888 DOI: 10.13004/kjnt.2023.19.e24] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/12/2023] Open
Abstract
Decompressive craniectomy (DCE) and cranioplasty (CP) are surgical procedures used to manage elevated intracranial pressure (ICP) in various clinical scenarios, including ischemic stroke, hemorrhagic stroke, and traumatic brain injury. The physiological changes following DCE, such as cerebral blood flow, perfusion, brain tissue oxygenation, and autoregulation, are essential for understanding the benefits and limitations of these procedures. A comprehensive literature search was conducted to systematically review the recent updates in DCE and CP, focusing on the fundamentals of DCE for ICP reduction, indications for DCE, optimal sizes and timing for DCE and CP, the syndrome of trephined, and the debate on suboccipital CP. The review highlights the need for further research on hemodynamic and metabolic indicators following DCE, particularly in relation to the pressure reactivity index. It provides recommendations for early CP within three months of controlling increased ICP to facilitate neurological recovery. Additionally, the review emphasizes the importance of considering suboccipital CP in patients with persistent headaches, cerebrospinal fluid leakage, or cerebellar sag after suboccipital craniectomy. A better understanding of the physiological effects, indications, complications, and management strategies for DCE and CP to control elevated ICP will help optimize patient outcomes and improve the overall effectiveness of these procedures.
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Affiliation(s)
- Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Heewon Jeong
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jiwoong Oh
- Division of Neurotrauma & Neurocritical Care Medicine, Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungjoo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abulhasan YB, Teitelbaum J, Al-Ramadhani K, Morrison KT, Angle MR. Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support. Neurology 2023; 100:e1985-e1995. [PMID: 36927881 PMCID: PMC10186215 DOI: 10.1212/wnl.0000000000207132] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 01/17/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Despite decades of increasingly sophisticated neurocritical care, patient outcomes after spontaneous intracerebral hemorrhage (ICH) remain dismal. Whether this reflects therapeutic nihilism or the effects of the primary injury has been questioned. In this contemporary cohort, we determined the 30- and 90-day mortality, cause-specific mortality, functional outcome, and the effect of surgical intervention in a culture of aggressive medical and surgical support. METHODS This was a retrospective cohort study of consecutive adult patients with spontaneous ICH admitted to a tertiary neurocritical care unit. Patients with secondary ICH and those subject to limitation of care before 72 hours were excluded. For each ICH score, mortality at 30- and 90-days, and the modified Rankin Scale (mRS) within 1-year were examined. The effect of craniotomy/craniectomy ± hematoma evacuation on the outcome of supratentorial ICH was determined using propensity score matching. Median patient follow-up after discharge was 2.2 (interquartile range [IQR] 0.4-4.4) years. RESULTS Among 319 patients with spontaneous ICH (median age was 69 [IQR 60-77] years, 60% male), 30- and 90-day mortality were 16% and 22%, respectively, and unfavorable functional outcome (mRS score 4-6) was 50% at a median 3.1 months after ICH. Admission predictors of mortality mirrored those of the original ICH score. Unfavorable outcomes for ICH scores 3 and 4 were 73% and 86%, respectively. The most common adjudicated primary causes of mortality were direct effect or progression of ICH (54%), refractory cerebral edema (21%), and medical complications (11%). In matched analyses, lifesaving surgery for supratentorial ICH did not significantly alter mortality or unfavorable functional outcome in patients overall. In subgroup analyses restricted to (1) surgery with hematoma evacuation and (2) ICH score 3 and 4 patients, the odds of 30-day mortality were reduced by 71% (odds ratio [OR] 0.29, 95% CI 0.09-0.9, p = 0.032) and 80% (OR 0.2, 95% CI 0.04-0.91, p = 0.038), respectively, but no difference was observed for 90-day mortality or unfavorable functional outcome. DISCUSSION This study demonstrates that poor outcomes after ICH prevail despite aggressive treatment. Unfavorable outcomes appear related to direct effects of the primary injury and not to premature care limitations. Lifesaving surgery for supratentorial lesions delayed mortality but did not alter functional outcomes.
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Affiliation(s)
- Yasser B Abulhasan
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada.
| | - Jeanne Teitelbaum
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada
| | - Khalsa Al-Ramadhani
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada
| | - Kathryn T Morrison
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada
| | - Mark R Angle
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada
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Maas AIR, Hemphill JC, Wilson L, Manley GT. Managing outcome expectations after Traumatic Brain Injury. Injury 2023; 54:1233-1235. [PMID: 37055145 DOI: 10.1016/j.injury.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Affiliation(s)
- Andrew I R Maas
- Antwerp University Hospital, Edegem, and University of Antwerp, Edegem, Belgium.
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco; Building 1, Room 101, 1001 Potrero Avenue, San Francisco, CA, 94110, United States of America; Department of Neurological Surgery, University of California, San Francisco, Brain & Spinal Injury Center, 1001 Potrero Avenue, San Francisco, CA, 94110, United States of America
| | - Lindsay Wilson
- Division of Psychology, School of Natural Sciences, University of Stirling, Stirling FK9 4LA, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, Brain & Spinal Injury Center, 1001 Potrero Avenue, San Francisco, CA, 94110, United States of America
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O'Donnell JC, Browne KD, Kvint S, Makaron L, Grovola MR, Karandikar S, Kilbaugh TJ, Cullen DK, Petrov D. Multimodal Neuromonitoring and Neurocritical Care in Swine to Enhance Translational Relevance in Brain Trauma Research. Biomedicines 2023; 11:biomedicines11051336. [PMID: 37239007 DOI: 10.3390/biomedicines11051336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Neurocritical care significantly impacts outcomes after moderate-to-severe acquired brain injury, but it is rarely applied in preclinical studies. We created a comprehensive neurointensive care unit (neuroICU) for use in swine to account for the influence of neurocritical care, collect clinically relevant monitoring data, and create a paradigm that is capable of validating therapeutics/diagnostics in the unique neurocritical care space. Our multidisciplinary team of neuroscientists, neurointensivists, and veterinarians adapted/optimized the clinical neuroICU (e.g., multimodal neuromonitoring) and critical care pathways (e.g., managing cerebral perfusion pressure with sedation, ventilation, and hypertonic saline) for use in swine. Moreover, this neurocritical care paradigm enabled the first demonstration of an extended preclinical study period for moderate-to-severe traumatic brain injury with coma beyond 8 h. There are many similarities with humans that make swine an ideal model species for brain injury studies, including a large brain mass, gyrencephalic cortex, high white matter volume, and topography of basal cisterns, amongst other critical factors. Here we describe the neurocritical care techniques we developed and the medical management of swine following subarachnoid hemorrhage and traumatic brain injury with coma. Incorporating neurocritical care in swine studies will reduce the translational gap for therapeutics and diagnostics specifically tailored for moderate-to-severe acquired brain injury.
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Affiliation(s)
- John C O'Donnell
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kevin D Browne
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Svetlana Kvint
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Leah Makaron
- University Laboratory Animal Resources, Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael R Grovola
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Saarang Karandikar
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Todd J Kilbaugh
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - D Kacy Cullen
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Dmitriy Petrov
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Dietvorst S, Depreitere B, Meyfroidt G. Beyond intracranial pressure: monitoring cerebral perfusion and autoregulation in severe traumatic brain injury. Curr Opin Crit Care 2023; 29:85-88. [PMID: 36762674 DOI: 10.1097/mcc.0000000000001026] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Severe traumatic brain injury (TBI) remains the most prevalent neurological condition worldwide. Observational and interventional studies provide evidence to recommend monitoring of intracranial pressure (ICP) in all severe TBI patients. Existing guidelines focus on treating elevated ICP and optimizing cerebral perfusion pressure (CPP), according to fixed universal thresholds. However, both ICP and CPP, their target thresholds, and their interaction, need to be interpreted in a broader picture of cerebral autoregulation, the natural capacity to adjust cerebrovascular resistance to preserve cerebral blood flow in response to external stimuli. RECENT FINDINGS Cerebral autoregulation is often impaired in TBI patients, and monitoring cerebral autoregulation might be useful to develop personalized therapy rather than treatment of one size fits all thresholds and guidelines based on unidimensional static relationships. SUMMARY Today, there is no gold standard available to estimate cerebral autoregulation. Cerebral autoregulation can be triggered by performing a mean arterial pressure (MAP) challenge, in which MAP is increased by 10% for 20 min. The response of ICP (increase or decrease) will estimate the status of cerebral autoregulation and can steer therapy mainly concerning optimizing patient-specific CPP. The role of cerebral metabolic changes and its relationship to cerebral autoregulation is still unclear and awaits further investigation.
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Affiliation(s)
| | | | - Geert Meyfroidt
- Department of Intensive Care, University Hospitals Leuven, Leuven, Belgium
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Svedung Wettervik T, Lewén A, Enblad P. Fine tuning of neurointensive care in aneurysmal subarachnoid hemorrhage: From one-size-fits-all towards individualized care. World Neurosurg X 2023; 18:100160. [PMID: 36818739 PMCID: PMC9932216 DOI: 10.1016/j.wnsx.2023.100160] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/25/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe type of acute brain injury with high mortality and burden of neurological sequelae. General management aims at early aneurysm occlusion to prevent re-bleeding, cerebrospinal fluid drainage in case of increased intracranial pressure and/or acute hydrocephalus, and cerebral blood flow augmentation in case of delayed ischemic neurological deficits. In addition, the brain is vulnerable to physiological insults in the acute phase and neurointensive care (NIC) is important to optimize the cerebral physiology to avoid secondary brain injury. NIC has led to significantly better neurological recovery following aSAH, but there is still great room for further improvements. First, current aSAH NIC management protocols are to some extent extrapolated from those in traumatic brain injury, notwithstanding important disease-specific differences. Second, the same NIC management protocols are applied to all aSAH patients, despite great patient heterogeneity. Third, the main variables of interest, intracranial pressure and cerebral perfusion pressure, may be too superficial to fully detect and treat several important pathomechanisms. Fourth, there is a lack of understanding not only regarding physiological, but also cellular and molecular pathomechanisms and there is a need to better monitor and treat these processes. This narrative review aims to discuss current state-of-the-art NIC of aSAH, knowledge gaps in the field, and future directions towards a more individualized care in the future.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
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Servadei F, Cannizzaro D, Zaed I, Iaccarino C, Cardia A. Neurotrauma Care: A Worldwide Perspective. J Neurotrauma 2023; 40:597-601. [PMID: 36893218 DOI: 10.1089/neu.2023.29137.fs] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Affiliation(s)
- Franco Servadei
- Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
| | - Delia Cannizzaro
- Humanitas Clinical and Research Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
| | - Ismail Zaed
- Department of Neurosurgery, Neurocenter of South Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Corrado Iaccarino
- Neurosurgery Unit, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Cardia
- Department of Neurosurgery, Neurocenter of South Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
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Role of NKCC1 and KCC2 during hypoxia-induced neuronal swelling in the neonatal neocortex. Neurobiol Dis 2023; 178:106013. [PMID: 36706928 PMCID: PMC9945323 DOI: 10.1016/j.nbd.2023.106013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/21/2022] [Accepted: 01/22/2023] [Indexed: 01/26/2023] Open
Abstract
Neonatal hypoxia causes cytotoxic neuronal swelling by the entry of ions and water. Multiple water pathways have been implicated in neurons because these cells lack water channels, and their membrane has a low water permeability. NKCC1 and KCC2 are cation-chloride cotransporters (CCCs) involved in water movement in various cell types. However, the role of CCCs in water movement in neonatal neurons during hypoxia is unknown. We studied the effects of modulating CCCs pharmacologically on neuronal swelling in the neocortex (layer IV/V) of neonatal mice (post-natal day 8-13) during prolonged and brief hypoxia. We used acute brain slices from Clomeleon mice which express a ratiometric fluorophore sensitive to Cl- and exposed them to oxygen-glucose deprivation (OGD) while imaging neuronal size and [Cl-]i by multiphoton microscopy. Neurons were identified using a convolutional neural network algorithm, and changes in the somatic area and [Cl-]i were evaluated using a linear mixed model for repeated measures. We found that (1) neuronal swelling and Cl- accumulation began after OGD, worsened during 20 min of OGD, or returned to baseline during reoxygenation if the exposure to OGD was brief (10 min). (2) Neuronal swelling did not occur when the extracellular Cl- concentration was low. (3) Enhancing KCC2 activity did not alter OGD-induced neuronal swelling but prevented Cl- accumulation; (4) blocking KCC2 led to an increase in Cl- accumulation during prolonged OGD and aggravated neuronal swelling during reoxygenation; (5) blocking NKCC1 reduced neuronal swelling during early but not prolonged OGD and aggravated Cl- accumulation during prolonged OGD; and (6) treatment with the "broad" CCC blocker furosemide reduced both swelling and Cl- accumulation during prolonged and brief OGD, whereas simultaneous NKCC1 and KCC2 inhibition using specific pharmacological blockers aggravated neuronal swelling during prolonged OGD. We conclude that CCCs, and other non-CCCs, contribute to water movement in neocortical neurons during OGD in the neonatal period.
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Alvarado-Dyer R, Aguilera S, Chesnut RM, Videtta W, Fischer D, Jibaja M, Godoy DA, Garcia RM, Goldenberg FD, Lazaridis C. Managing Severe Traumatic Brain Injury Across Resource Settings: Latin American Perspectives. Neurocrit Care 2023; 38:229-234. [PMID: 36635495 PMCID: PMC9836742 DOI: 10.1007/s12028-022-01670-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/19/2022] [Indexed: 01/14/2023]
Abstract
Severe traumatic brain injury (sTBI) is a condition of increasing epidemiologic concern worldwide. Outcomes are worse as observed in low- and middle-income countries (LMICs) versus high-income countries. Global targets are in place to address the surgical burden of disease. At the same time, most of the published literature and evidence on the clinical approach to sTBI comes from wealthy areas with an abundance of resources. The available paradigms, including the Brain Trauma Foundation guidelines, the Seattle International Severe Traumatic Brain Injury Consensus Conference, Consensus Revised Imaging and Clinical Examination, and multimodality approaches, may fit differently depending on local resources, expertise, and sociocultural factors. A first step toward addressing heterogeneity in practice is to consider comparative effectiveness approaches that can capture actual practice patterns and record short-term and long-term outcomes of interest. Decompressive craniectomy (DC) decreases intracranial pressure burden and can be lifesaving. Nevertheless, completed randomized controlled trials took place within high-income settings, leaving important questions unanswered and making extrapolations to LMICs questionable. The concept of preemptive DC specifically to address limited neuromonitoring resources may warrant further study to establish a benefit/risk profile for the procedure and its role within local protocols of care.
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Affiliation(s)
- Ronald Alvarado-Dyer
- Division of Neurocritical Care, Departments of Neurology, and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637 USA
| | - Sergio Aguilera
- Neurosurgery, Herminda Martin Hospital-Chillán Valparaíso University, Valparaíso, Chile
| | | | - Walter Videtta
- Intensive Care, Posadas Hospital, Buenos Aires, Argentina
| | - Danilo Fischer
- Intensive Care, School of Medicine, Universidad de los Andes, Santiago, Chile
| | - Manuel Jibaja
- Intensive Care, Hospital Eugenio Espejo, School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador
| | | | - Roxanna M. Garcia
- Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Fernando D. Goldenberg
- Division of Neurocritical Care, Departments of Neurology, and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637 USA
| | - Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology, and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637 USA
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Robba C, Graziano F, Guglielmi A, Rebora P, Galimberti S, Taccone FS, Citerio G. Treatments for intracranial hypertension in acute brain-injured patients: grading, timing, and association with outcome. Data from the SYNAPSE-ICU study. Intensive Care Med 2023; 49:50-61. [PMID: 36622462 PMCID: PMC9852114 DOI: 10.1007/s00134-022-06937-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/08/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Uncertainties remain about the safety and efficacy of therapies for managing intracranial hypertension in acute brain injured (ABI) patients. This study aims to describe the therapeutical approaches used in ABI, with/without intracranial pressure (ICP) monitoring, among different pathologies and across different countries, and their association with six months mortality and neurological outcome. METHODS A preplanned subanalysis of the SYNAPSE-ICU study, a multicentre, prospective, international, observational cohort study, describing the ICP treatment, graded according to Therapy Intensity Level (TIL) scale, in patients with ABI during the first week of intensive care unit (ICU) admission. RESULTS 2320 patients were included in the analysis. The median age was 55 (I-III quartiles = 39-69) years, and 800 (34.5%) were female. During the first week from ICU admission, no-basic TIL was used in 382 (16.5%) patients, mild-moderate in 1643 (70.8%), and extreme in 295 cases (eTIL, 12.7%). Patients who received eTIL were younger (median age 49 (I-III quartiles = 35-62) vs 56 (40-69) years, p < 0.001), with less cardiovascular pre-injury comorbidities (859 (44%) vs 90 (31.4%), p < 0.001), with more episodes of neuroworsening (160 (56.1%) vs 653 (33.3%), p < 0.001), and were more frequently monitored with an ICP device (221 (74.9%) vs 1037 (51.2%), p < 0.001). Considerable variability in the frequency of use and type of eTIL adopted was observed between centres and countries. At six months, patients who received no-basic TIL had an increased risk of mortality (Hazard ratio, HR = 1.612, 95% Confidence Interval, CI = 1.243-2.091, p < 0.001) compared to patients who received eTIL. No difference was observed when comparing mild-moderate TIL with eTIL (HR = 1.017, 95% CI = 0.823-1.257, p = 0.873). No significant association between the use of TIL and neurological outcome was observed. CONCLUSIONS During the first week of ICU admission, therapies to control high ICP are frequently used, especially mild-moderate TIL. In selected patients, the use of aggressive strategies can have a beneficial effect on six months mortality but not on neurological outcome.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Science and Integrated Diagnostic, University of Genoa, Genoa, Italy
| | - Francesca Graziano
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Angelo Guglielmi
- Department of Clinical-Surgical Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Stefania Galimberti
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
- Bicocca Bioinformatics Biostatistics and Bioimaging Center B4, School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.
- Neuroscience Department, NeuroIntensive Care Unit, Hospital San Gerardo, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
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