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Kölbel B, Novotny A, Willms A, Kehl V, Meyer B, Mauer UM, Krieg SM. Study protocol for a multicenter randomized controlled pilot study on decompressive laparotomy vs. decompressive craniectomy for intractable intracranial pressure after traumatic brain injury: The SCALPEL study. BRAIN & SPINE 2023; 3:102677. [PMID: 37822567 PMCID: PMC10562836 DOI: 10.1016/j.bas.2023.102677] [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: 07/07/2023] [Revised: 09/05/2023] [Accepted: 09/17/2023] [Indexed: 10/13/2023]
Abstract
Introduction Decompressive craniectomy (DC) is the ultimate intervention to lower intracranial pressure (ICP) following severe traumatic brain injury (TBI). However, this intervention is associated with considerable adverse events and a higher proportion of survivors with poor functional outcomes. Research question In a multicompartment system ICP is associated with intraabdominal pressure (IAP) due to cerebral venous outflow from the brain. This is the rationale for decompressive laparotomy (DL) to control ICP after TBI as reported by experimental and retrospective clinical data. The safety profile of DL is superior to DC. This study aims to randomly assign patients with intractable high ICP after severe TBI to DL or DC. Material and methods Among other inclusion criteria, ICP must be above 20 mmHg (1-12 h) despite sedation and all other measures according to current guidelines. The primary outcome is the Extended Glasgow Outcome Scale assessed after twelve months. Further secondary outcome measures are compartmental pressure values, complications, etc. After 20 initial patients, results will be reviewed by the ethics committees and safety monitoring board to decide on the enrolment of 80 additional patients. Results The study is designed to provide not only high-quality prospective data for the first time on this treatment approach, its two-stage design (20 + 80 pts) also provides maximum patient safety. This protocol conforms with the SPIRIT 2013 Statement. Ethics approval was granted by our but also 5 other university ethics committees (registration 473/18S). Conclusion Registration was performed prior to study initiation in November 2021 (registration number NCT05115929).
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Affiliation(s)
- Benny Kölbel
- Department of Surgery, Bundeswehrkrankenhaus Ulm, Germany
| | - Alexander Novotny
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Arnulf Willms
- Department of Surgery, Bundeswehrkrankenhaus Hamburg, Germany
| | - Victoria Kehl
- Münchner Studienzentrum, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Uwe-Max Mauer
- Department of Neurosurgery, Bundeswehrkrankenhaus Ulm, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Dincer A, Stanton AN, Parham KJ, Carr MT, Opalak CF, Valadka AB, Broaddus WC. The Richmond Acute Subdural Hematoma Score: A Validated Grading Scale to Predict Postoperative Mortality. Neurosurgery 2022; 90:278-286. [PMID: 35113829 DOI: 10.1227/neu.0000000000001786] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 09/19/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Traumatic acute subdural hematomas (aSDHs) are common, life-threatening injuries often requiring emergency surgery. OBJECTIVE To develop and validate the Richmond acute subdural hematoma (RASH) score to stratify patients by risk of mortality after aSDH evacuation. METHODS The 2016 National Trauma Data Bank (NTDB) was queried to identify adult patients with traumatic aSDHs who underwent craniectomy or craniotomy within 4 h of arrival to an emergency department. Multivariate logistic regression modeling identified risk factors independently associated with mortality. The RASH score was developed based on a factor's strength and level of association with mortality. The model was validated using the 2017 NTDB and the area under the receiver operating characteristic curve (AUC). RESULTS A total of 2516 cases met study criteria. The patients were 69.3% male with a mean age of 55.7 yr and overall mortality rate of 36.4%. Factors associated with mortality included age between 61 and 79 yr (odds ratio [OR] = 2.3, P < .001), age ≥80 yr (OR = 6.3, P < .001), loss of consciousness (OR = 2.3, P < .001), Glasgow Coma Scale score of ≤8 (OR = 2.6, P < .001), unilateral (OR = 2.8, P < .001) or bilateral (OR = 3.9, P < .001) unresponsive pupils, and midline shift >5 mm (OR = 1.7, P < .001). Using these risk factors, the RASH score predicted progressively increasing mortality ranging from 0% to 94% for scores of 0 to 8, respectively (AUC = 0.72). Application of the RASH score to 3091 cases from 2017 resulted in similar accuracy (AUC = 0.74). CONCLUSION The RASH score is a simple and validated grading scale that uses easily accessible preoperative factors to predict estimated mortality rates in patients with traumatic aSDHs who undergo surgical evacuation.
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Affiliation(s)
- Alper Dincer
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, USA
| | - Amanda N Stanton
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kevin J Parham
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Matthew T Carr
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Charles F Opalak
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alex B Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - William C Broaddus
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
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Abouhashem S, Albakry A, El-Atawy S, Fawzy F, Elgammal S, Khattab O. Prediction of early mortality after primary decompressive craniectomy in patients with severe traumatic brain injury. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-020-00096-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objectives
Traumatic brain injury (TBI) is a worldwide major health problem associated with a high rate of morbidity and mortality. Intracranial hypertension following TBI is the main but not the only cause of early mortality. Decompressive craniectomy (DC) is used to decrease the intracranial pressure (ICP) and prevent brain herniation following TBI; however, the clinical outcome after DC for patients with TBI generates continuous debate. Prediction of early mortality after DC will help in making the surgery decision.
The aim of this study is to predict early mortality after DC based on the initial clinical and radiological findings.
Methods
In this study, 104 patients with severe traumatic brain injury have been treated by decompressive craniectomy and were retrospectively analyzed. Patients were divided into two groups; group I involved 32 patients who died within 28 days while group II involved 72 patients who survived after 28 days. The relationship between initial Glasgow Coma Scale score (GCS), pupil size and reactivity, associated injuries, and radiological findings were analyzed as predictor factors for early mortality.
Results
A total of 104 patients with severe TBI have been treated by DC and were analyzed; the early mortality occurred in 32 patients, 30.77%. There is a significant difference between groups in gender, mean GCS, Marshall scale, presence of isochoric pupils, and lung injury.
After stratification, odds of early mortality increases with the lower GCS, higher Marshall scale, lung injury, and abdominal injury while male gender and the presence of isochoric pupils decrease the odds of mortality. After univariate regression, the significant impact of GCS disappears except for GCS-8 which decreases the odds of mortality in comparison to other GCS scores while higher Marshall scale, presence of isochoric pupils, and lung injury increase the odds of mortality, but most of these effects disappear after multiple regressions except for lung injury and isochoric pupils.
Conclusion
Prediction of early mortality after DC is multifactorial, but the odds of early mortality after decompressive craniectomy in severe traumatic brain injury are progressively increased with the lower GCS, higher Marshall scale, and the presence of lung or abdominal injury.
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Tsaousi GG, Marocchi L, Sergi PG, Pourzitaki C, Santoro A, Bilotta F. Early and late clinical outcomes after decompressive craniectomy for traumatic refractory intracranial hypertension: a systematic review and meta-analysis of current evidence. J Neurosurg Sci 2018; 64:97-106. [PMID: 30356035 DOI: 10.23736/s0390-5616.18.04527-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Decompressive craniectomy (DC) to control refractory intracranial hypertension in patients with traumatic brain injury (TBI), has been listed as possible but controversial therapeutic approach in the latest version of TBI management guidelines. This study aimed to perform a systematic review and meta-analysis on efficacy and safety of DC compared to standard care in TBI patients. EVIDENCE ACQUISITION A database search from 2011 to 2017 was conducted to identify studies pertinent to DC compared to standard care after TBI. The primary outcomes were mortality and functional outcome upon hospital discharge and at 6 and 12 months after intervention, whereas secondary outcomes were intracranial pressure (ICP) control, hospitalization data and occurrence of adverse events. EVIDENCE SYNTHESIS Three randomized controlled trials and two observational studies enrolling 3451 patients were selected for qualitative analysis, among which four were included in the meta-analysis. DC-treated patients showed a significant reduction of overall mortality (RR, 0.57; 95% CI: 0.5-0.66; P<0.001; I2=17%) with no profound beneficial effect on functional outcome (RR, 0.89; 95% CI: 0.78-1.02; P=0.09; I2=58%) compared to those receiving standard care. A more efficient ICP reduction and a tendency towards shorter duration of hospitalization were recorded in DC versus standard care group. Adverse events are more common in DC-treated patients. CONCLUSIONS It seems that, in TBI patients with intracranial hypertension, the use of DC is associated with survival benefit when compared to medical therapy alone, but with no clear improvement of functional outcome. Yet no definite conclusion can be drawn due to limited quantity and considerable heterogeneity of available data.
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Affiliation(s)
- Georgia G Tsaousi
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece -
| | - Lorenzo Marocchi
- Department of Anesthesiology and Intensive Care Medicine, Sapienza University, Rome, Italy
| | - Paola G Sergi
- Department of Anesthesiology and Intensive Care Medicine, Sapienza University, Rome, Italy
| | - Chryssa Pourzitaki
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonio Santoro
- Department of Neurosurgery, Sapienza University, Rome, Italy
| | - Federico Bilotta
- Department of Anesthesiology and Intensive Care Medicine, Sapienza University, Rome, Italy
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Kamiutsuri K, Tominaga N, Kobayashi S. Preoperative elevated FDP may predict severe intraoperative hypotension after dural opening during decompressive craniectomy of traumatic brain injury. JA Clin Rep 2018; 4:8. [PMID: 29457118 PMCID: PMC5804671 DOI: 10.1186/s40981-018-0146-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/04/2018] [Indexed: 01/30/2023] Open
Abstract
Purpose Coagulation disorder and intraoperative hypotension are representative complications of traumatic brain injury which cause worse perioperative outcome. The aim of this study was to survey the relation of coagulation disorder and intraoperative hypotension (IH) during decompressive craniectomy. Method Patients who underwent emergency decompressive craniectomy due to traumatic brain injury were retrospectively surveyed. The relation between preoperative coagulation date and intraoperative hypotension (systolic blood pressure < 60 mmHg after dural opening) was analyzed. Results Of 41 patients screened, 12 patients (27.9%) developed IH. Fibrinogen degradation products (314 vs 64.4 μg/mL; p = 0.01) were significantly higher in the IH group. In contrast, fibrinogen (181 vs 239 mg/dL; p = 0.01) was significantly lower in the IH group. Reduction rate of sBRP before and after dural opening (%) was higher in IH group than in non-IH group (49.1 vs 27.6%: p = 0.001). Conclusions Preoperative elevated FDP may predict IH after dural opening during traumatic decompressive craniectomy.
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Affiliation(s)
- Kei Kamiutsuri
- Department of Anesthesiology, Rinku General Medical Center, Izumisano, Japan.
| | - Naoki Tominaga
- Department of Cardiovascular Internal Medicine, Shin Komonji Hospital, Kitakyushu, Japan
| | - Shunji Kobayashi
- Department of Anesthesiology, Rinku General Medical Center, Izumisano, Japan
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Fountain DM, Kolias AG, Lecky FE, Bouamra O, Lawrence T, Adams H, Bond SJ, Hutchinson PJ. Survival Trends After Surgery for Acute Subdural Hematoma in Adults Over a 20-year Period. Ann Surg 2017; 265:590-596. [PMID: 27172128 PMCID: PMC5300032 DOI: 10.1097/sla.0000000000001682] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We sought to determine 30-day survival trends and prognostic factors following surgery for acute subdural hematomas (ASDHs) in England and Wales over a 20-year period. SUMMARY OF BACKGROUND DATA ASDHs are still considered the most lethal type of traumatic brain injury. It remains unclear whether the adjusted odds of survival have improved significantly over time. METHODS Using the Trauma Audit and Research Network (TARN) database, we analyzed ASDH cases in the adult population (>16 yrs) treated surgically between 1994 and 2013. Two thousand four hundred ninety-eight eligible cases were identified. Univariable and multiple logistic regression analyses were performed, using multiple imputation for missing data. RESULTS The cohort was 74% male with a median age of 48.9 years. Over half of patients were comatose at presentation (53%). Mechanism of injury was due to a fall (<2 m 34%, >2 m 24%), road traffic collision (25%), and other (17%). Thirty-six per cent of patients presented with polytrauma. Gross survival increased from 59% in 1994 to 1998 to 73% in 2009 to 2013. Under multivariable analysis, variables independently associated with survival were year of injury, Glasgow Coma Scale, Injury Severity Score, age, and pupil reactivity. The time interval from injury to craniotomy and direct admission to a neurosurgical unit were not found to be significant prognostic factors. CONCLUSIONS A significant improvement in survival over the last 20 years was observed after controlling for multiple prognostic factors. Prospective trials and cohort studies are expected to elucidate the distribution of functional outcome in survivors.
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Affiliation(s)
- Daniel M. Fountain
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Fiona E. Lecky
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
- Emergency Medicine Research in Sheffield (EMRiS), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Omar Bouamra
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Thomas Lawrence
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Simon J. Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- MRC Biostatistics Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
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Fountain DM, Kolias AG, Laing RJ, Hutchinson PJ. The financial outcome of traumatic brain injury: a single centre study. Br J Neurosurg 2016; 31:350-355. [PMID: 27774811 DOI: 10.1080/02688697.2016.1244254] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Severe traumatic brain injury (TBI) is a potentially devastating insult to the brain with high rates of fatality and neurological deficits. TBI can result in substantial costs to the centre providing care. We sought to present the experience of a Major Trauma Centre (MTC) and ascertain the financial implications of this healthcare provision, in particular detailed costs, reimbursement and the surplus or deficit accrued by the centre. DESIGN All cranial non-elective neurosurgical admissions with a TBI over 4.5 months (26 October 2014 to 15 March 2015) were analysed retrospectively, excluding cases of chronic subdural haematoma, at an MTC in England. Demographic data were collected alongside detailed cost and income data. RESULTS Ninety four patients were identified. The majority of patients presented with more than one diagnosis of cranial trauma. Average length of stay was 18.8 ± 21.6 days. Total deficits as a result of treating this cohort amounted to £558,034. There was a significant association between (i) more complex presentations and (ii) a longer length of stay and the deficit accrued by the centre. The major drivers of the financial outcome were costs associated with wards, medical staffing and overheads. CONCLUSION There was a substantial deficit accrued as a result of the management of patients with TBI at an MTC. The more complex the presentation, extensive the intervention, and lengthy the stay, the greater the deficit accrued by the centre. The current tariff payment system is not effectively reflecting the severity of injury or intensity of management of patients with TBI.
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Affiliation(s)
- Daniel M Fountain
- a Division of Neurosurgery , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Angelos G Kolias
- a Division of Neurosurgery , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Rodney J Laing
- a Division of Neurosurgery , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Peter J Hutchinson
- a Division of Neurosurgery , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
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Erroneous Methodology in "Craniotomy Versus Craniectomy for Acute Traumatic Subdural Hematoma in the United States: A National Retrospective Cohort Analysis". World Neurosurg 2016; 91:650-1. [PMID: 27432643 DOI: 10.1016/j.wneu.2016.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 11/24/2022]
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Kolias AG, Adams H, Timofeev I, Czosnyka M, Corteen EA, Pickard JD, Turner C, Gregson BA, Kirkpatrick PJ, Murray GD, Menon DK, Hutchinson PJ. Decompressive craniectomy following traumatic brain injury: developing the evidence base. Br J Neurosurg 2016; 30:246-50. [PMID: 26972805 PMCID: PMC4841020 DOI: 10.3109/02688697.2016.1159655] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
In the context of traumatic brain injury (TBI), decompressive craniectomy (DC) is used as part of tiered therapeutic protocols for patients with intracranial hypertension (secondary or protocol-driven DC). In addition, the bone flap can be left out when evacuating a mass lesion, usually an acute subdural haematoma (ASDH), in the acute phase (primary DC). Even though, the principle of "opening the skull" in order to control brain oedema and raised intracranial pressure has been practised since the beginning of the 20th century, the last 20 years have been marked by efforts to develop the evidence base with the conduct of randomised trials. This article discusses the merits and challenges of this approach and provides an overview of randomised trials of DC following TBI. An update on the RESCUEicp study, a randomised trial of DC versus advanced medical management (including barbiturates) for severe and refractory post-traumatic intracranial hypertension is provided. In addition, the rationale for the RESCUE-ASDH study, the first randomised trial of primary DC versus craniotomy for adult head-injured patients with an ASDH, is presented.
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Affiliation(s)
- Angelos G Kolias
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Hadie Adams
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Ivan Timofeev
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Marek Czosnyka
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Elizabeth A Corteen
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - John D Pickard
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Carole Turner
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Barbara A Gregson
- b Institute of Neuroscience, Neurosurgical Trials Group , Newcastle University , Newcastle , UK
| | - Peter J Kirkpatrick
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Gordon D Murray
- c Centre for Population Health Sciences, University of Edinburgh , Edinburgh , UK
| | - David K Menon
- d Division of Anaesthesia , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Peter J Hutchinson
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
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