Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

Exosomes derived from microglia overexpressing miR-124-3p alleviate neuronal endoplasmic reticulum stress damage after repetitive mild traumatic brain injury

JOURNAL/nrgr/04.03/01300535-202409000-00033/figure1/v/2024-01-16T170235Z/r/image-tiff We previously reported that miR-124-3p is markedly upregulated in microglia-derived exosomes following repetitive mild traumatic brain injury. However, its impact on neuronal endoplasmic reticulum stress following repetitive mild traumatic brain injury remains unclear. In this study, we first used an HT22 scratch injury model to mimic traumatic brain injury, then co-cultured the HT22 cells with BV2 microglia expressing high levels of miR-124-3p. We found that exosomes containing high levels of miR-124-3p attenuated apoptosis and endoplasmic reticulum stress. Furthermore, luciferase reporter assay analysis confirmed that miR-124-3p bound specifically to the endoplasmic reticulum stress-related protein IRE1α, while an IRE1α functional salvage experiment confirmed that miR-124-3p targeted IRE1α and reduced its expression, thereby inhibiting endoplasmic reticulum stress in injured neurons. Finally, we delivered microglia-derived exosomes containing miR-124-3p intranasally to a mouse model of repetitive mild traumatic brain injury and found that endoplasmic reticulum stress and apoptosis levels in hippocampal neurons were significantly reduced. These findings suggest that, after repetitive mild traumatic brain injury, miR-124-3 can be transferred from microglia-derived exosomes to injured neurons, where it exerts a neuroprotective effect by inhibiting endoplasmic reticulum stress. Therefore, microglia-derived exosomes containing miR-124-3p may represent a novel therapeutic strategy for repetitive mild traumatic brain injury.

Global Neurosurgery at the 76th World Health Assembly (2023): First Neurosurgery-Driven Resolution Calls for Micronutrient Fortification to Prevent Spina Bifida

Since 2018, a neurosurgery delegation has been actively engaged and consistently present at the World Health Assembly. Recognizing the growing impact of neurosurgical diseases, the neurosurgery delegation participated in the 76th World Health Assembly in May 2023, advocating for timely, safe, and affordable global neurosurgical care. The delegation focused on forging new collaborations, strengthening the World Health Organization-World Federation of Neurosurgical Societies official relations, and actively supporting resolutions that impact the neurosurgical patients. However, there is a long advocacy journey ahead to address unmet neurosurgical needs. Patient-centered advocacy is an inherent task of our profession and the essence of the Global Neurosurgery Bogota Declaration of 2016. The highlight of the 76th World Health Assembly was the adoption of the first neurosurgery-driven resolution calling for micronutrient fortification to prevent spina bifida and other micronutrient deficiencies. For the last 4 years, the Global Alliance for Prevention of Spina Bifida, a group spearheaded by neurosurgeons, advocated for spina bifida prevention. This Alliance collaborated with many stakeholders, notably, the Colombian government to promote the resolution: "Accelerating efforts for preventing micronutrient deficiencies and their consequences, including spina bifida and other neural tube defects, through safe and effective food fortification." This is a proud milestone for the neurosurgical profession. There are many strategies available for neurosurgeons, when working together with elected leaders, other stakeholders, and allied professionals, to implement initiatives that can prevent future cases of spina bifida and other neurological disorders and reduce the burden of neurosurgical disease.

Evaluating patient factors, operative management and postoperative outcomes in trauma laparotomy patients worldwide: a protocol for a global observational multicentre trauma study

INTRODUCTION

Trauma contributes to the greatest loss of disability-adjusted life-years for adolescents and young adults worldwide. In the context of global abdominal trauma, the trauma laparotomy is the most commonly performed operation. Variation likely exists in how these patients are managed and their subsequent outcomes, yet very little global data on the topic currently exists. The objective of the GOAL-Trauma study is to evaluate both patient and injury factors for those undergoing trauma laparotomy, their clinical management and postoperative outcomes.

METHODS

We describe a planned prospective multicentre observational cohort study of patients undergoing trauma laparotomy. We will include patients of all ages who present to hospital with a blunt or penetrating injury and undergo a trauma laparotomy within 5 days of presentation to the treating centre. The study will collect system, patient, process and outcome data, following patients up until 30 days postoperatively (or until discharge or death, whichever is first). Our sample size calculation suggests we will need to recruit 552 patients from approximately 150 recruiting centres.

DISCUSSION

The GOAL-Trauma study will provide a global snapshot of the current management and outcomes for patients undergoing a trauma laparotomy. It will also provide insight into the variation seen in the time delays for receiving care, the disease and patient factors present, and patient outcomes. For current standards of trauma care to be improved worldwide, a greater understanding of the current state of trauma laparotomy care is paramount if appropriate interventions and targets are to be identified and implemented.

Therapy Intensity Level Scale for Traumatic Brain Injury: Clinimetric Assessment on Neuro-Monitored Patients Across 52 European Intensive Care Units

Intracranial pressure (ICP) data from traumatic brain injury (TBI) patients in the intensive care unit (ICU) cannot be interpreted appropriately without accounting for the effect of administered therapy intensity level (TIL) on ICP. A 15-point scale was originally proposed in 1987 to quantify the hourly intensity of ICP-targeted treatment. This scale was subsequently modified-through expert consensus-during the development of TBI Common Data Elements to address statistical limitations and improve usability. The latest 38-point scale (hereafter referred to as TIL) permits integrated scoring for a 24-h period and has a five-category, condensed version (TIL(Basic)) based on qualitative assessment. Here, we perform a total- and component-score analysis of TIL and TIL(Basic) to: 1) validate the scales across the wide variation in contemporary ICP management; 2) compare their performance against that of predecessors; and 3) derive guidelines for proper scale use. From the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, we extract clinical data from a prospective cohort of ICP-monitored TBI patients (n = 873) from 52 ICUs across 19 countries. We calculate daily TIL and TIL(Basic) scores (TIL24 and TIL(Basic)24, respectively) from each patient's first week of ICU stay. We also calculate summary TIL and TIL(Basic) scores by taking the first-week maximum (TILmax and TIL(Basic)max) and first-week median (TILmedian and TIL(Basic)median) of TIL24 and TIL(Basic)24 scores for each patient. We find that, across all measures of construct and criterion validity, the latest TIL scale performs significantly greater than or similarly to all alternative scales (including TIL(Basic)) and integrates the widest range of modern ICP treatments. TILmedian outperforms both TILmax and summarized ICP values in detecting refractory intracranial hypertension (RICH) during ICU stay. The RICH detection thresholds which maximize the sum of sensitivity and specificity are TILmedian ≥ 7.5 and TILmax ≥ 14. The TIL24 threshold which maximizes the sum of sensitivity and specificity in the detection of surgical ICP control is TIL24 ≥ 9. The median scores of each TIL component therapy over increasing TIL24 reflect a credible staircase approach to treatment intensity escalation, from head positioning to surgical ICP control, as well as considerable variability in the use of cerebrospinal fluid drainage and decompressive craniectomy. Since TIL(Basic)max suffers from a strong statistical ceiling effect and only covers 17% (95% confidence interval [CI]: 16-18%) of the information in TILmax, TIL(Basic) should not be used instead of TIL for rating maximum treatment intensity. TIL(Basic)24 and TIL(Basic)median can be suitable replacements for TIL24 and TILmedian, respectively (with up to 33% [95% CI: 31-35%] information coverage) when full TIL assessment is infeasible. Accordingly, we derive numerical ranges for categorising TIL24 scores into TIL(Basic)24 scores. In conclusion, our results validate TIL across a spectrum of ICP management and monitoring approaches. TIL is a more sensitive surrogate for pathophysiology than ICP and thus can be considered an intermediate outcome after TBI.

Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization

Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.

Cerebral Glucose Metabolism following TBI: Changes in Plasma Glucose, Glucose Transport and Alternative Pathways of Glycolysis-A Translational Narrative Review

Traumatic brain injury (TBI) is a major public health concern with significant consequences across various domains. Following the primary event, secondary injuries compound the outcome after TBI, with disrupted glucose metabolism emerging as a relevant factor. This narrative review summarises the existing literature on post-TBI alterations in glucose metabolism. After TBI, the brain undergoes dynamic changes in brain glucose transport, including alterations in glucose transporters and kinetics, and disruptions in the blood-brain barrier (BBB). In addition, cerebral glucose metabolism transitions from a phase of hyperglycolysis to hypometabolism, with upregulation of alternative pathways of glycolysis. Future research should further explore optimal, and possibly personalised, glycaemic control targets in TBI patients, with GLP-1 analogues as promising therapeutic candidates. Furthermore, a more fundamental understanding of alterations in the activation of various pathways, such as the polyol and lactate pathway, could hold the key to improving outcomes following TBI.

Consensus-Based Development of a Global Registry for Traumatic Brain Injury: Establishment, Protocol, and Implementation

BACKGROUND AND OBJECTIVES

Global disparity exists in the demographics, pathology, management, and outcomes of surgically treated traumatic brain injury (TBI). However, the factors underlying these differences, including intervention effectiveness, remain unclear. Establishing a more accurate global picture of the burden of TBI represents a challenging task requiring systematic and ongoing data collection of patients with TBI across all management modalities. The objective of this study was to establish a global registry that would enable local service benchmarking against a global standard, identification of unmet need in TBI management, and its evidence-based prioritization in policymaking.

METHODS

The registry was developed in an iterative consensus-based manner by a panel of neurotrauma professionals. Proposed registry objectives, structure, and data points were established in 2 international multidisciplinary neurotrauma meetings, after which a survey consisting of the same data points was circulated within the global neurotrauma community. The survey results were disseminated in a final meeting to reach a consensus on the most pertinent registry variables.

RESULTS

A total of 156 professionals from 53 countries, including both high-income countries and low- and middle-income countries, responded to the survey. The final consensus-based registry includes patients with TBI who required neurosurgical admission, a neurosurgical procedure, or a critical care admission. The data set comprised clinically pertinent information on demographics, injury characteristics, imaging, treatments, and short-term outcomes. Based on the consensus, the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry was established.

CONCLUSION

The GEO-TBI registry will enable high-quality data collection, clinical auditing, and research activity, and it is supported by the World Federation of Neurosurgical Societies and the National Institute of Health Research Global Health Program. The GEO-TBI registry ( https://geotbi.org ) is now open for participant site recruitment. Any center involved in TBI management is welcome to join the collaboration to access the registry.

The Role of Automated Infrared Pupillometry in Traumatic Brain Injury: A Narrative Review

Pupillometry, an integral component of neurological examination, serves to evaluate both pupil size and reactivity. The conventional manual assessment exhibits inherent limitations, thereby necessitating the development of portable automated infrared pupillometers (PAIPs). Leveraging infrared technology, these devices provide an objective assessment, proving valuable in the context of brain injury for the detection of neuro-worsening and the facilitation of patient monitoring. In cases of mild brain trauma particularly, traditional methods face constraints. Conversely, in severe brain trauma scenarios, PAIPs contribute to neuro-prognostication and non-invasive neuromonitoring. Parameters derived from PAIPs exhibit correlations with changes in intracranial pressure. It is important to acknowledge, however, that PAIPs cannot replace invasive intracranial pressure monitoring while their widespread adoption awaits robust support from clinical studies. Ongoing research endeavors delve into the role of PAIPs in managing critical neuro-worsening in brain trauma patients, underscoring the non-invasive monitoring advantages while emphasizing the imperative for further clinical validation. Future advancements in this domain encompass sophisticated pupillary assessment tools and the integration of smartphone applications, emblematic of a continually evolving landscape.

The Effects of Neuromonitoring and Cerebrolysin Administration on Outcomes in Patients with Traumatic Brain Injury-An Interventional Pilot Study

INTRODUCTION

Traumatic brain injury (TBI) is one of the most common causes of death and an important burden to the worldwide healthcare system and society. There is a lack of guidelines for types of monitoring or neuroprotective therapy. The aim of this pilot study was to assess its feasibility and, furthermore, to evaluate the impact of Cerebrolysin on the following clinical outcomes: length of stay, Glasgow Outcome Scale (GOS) and mortality.

METHODS

A cohort of 56 patients was included in this non-randomised, real-time, pre-post-interventional study. The patients were assessed with the Glasgow Coma Scale (GCS) and divided into two groups: severe (GCS < 8) and non-severe (GCS > 8). After the radiological examination (CT scan), the patients were qualified for an immediate neurosurgical procedure if needed. The patients were admitted to the intensive care unit, where a standardised protocol for TBI treatment was implemented. Additional neuromonitoring was applied.

RESULTS

There were 56 patients (19 females; 33.9%), of which 41 were considered severe cases; the patients were allocated to the Cerebrolysin (n = 25) or control groups (n = 31). In a generalised linear model (GLM) approach, the use of Cerebrolysin was associated with a decrease in the probability of death in non-severe patients (by 0.333 (standard error (SE) = 0.157, p = 0.034)) but not in severe patients (estimate (Est.) = -0.115, SE = 0.127, p = 0.364). Patients who received Cerebrolysin and who were neuromonitored had favourable outcomes and better survival rates.

CONCLUSIONS

A multimodal treatment approach with monitoring and Cerebrolysin may have a beneficial effect on patients with less severe TBIs; however, the present study has multiple limitations, and further research is needed.

The incidence of VP shunt infection in a middle-income nation: a retrospective analysis of a pediatric population

Objective

To investigate the incidence of infection after ventriculoperitoneal shunt (VPS) insertion at the Bustamante Hospital for Children (BHC), Jamaica, West Indies.

Method

Of the 178 patients managed by the Neurosurgery team at BHC, who underwent surgery between 2010 and 2016, 122 patients were subjected to the cerebrospinal fluid (CSF) diversion procedure through a VPS placement. The patients excluded from this study included those with a VPS placed at another institution or one placed prior to the study period. There is a notable transition that saw a switch from the use of the Codman uni-port to Medtronic shunts in 2014-2015, which initiated the process of reuse of shunt passers. Clinical data were retrospectively collected from operating theater logs and available manual health records.

Results

Over the 7-year study period of the 122 first-time shunt placements done, 17 patients (13.9%) had positive CSF cultures, with an additional six (4%) having CSF pleocytosis with negative cultures. The most common isolate was the Staphylococcus species, occurring in 60% of VPS infections. The median time to shunt infection was 2 months. Of the 72 Codman shunts placed, six became infected, and 21.7% (10 of 46) of the Medtronic shunts became infected.

Conclusion

The rate of incidence of VPS infection was 13.9% for the period between 2010 and 2016, with most infections occurring after 2014. The major causative agent was Staphylococcus species at 60% within a median 2 months of surgery. Overall, this compares well with data reported in the literature.

Traumatic spinal cord injury: acute phase treatment in critical care

PURPOSE OF REVIEW

Surgical timing in traumatic spinal cord injury (t-SCI) remains a point of debate. Current guidelines recommend surgery within 24 h after trauma; however, earlier timeframes are currently intensively being investigated. The aim of this review is to provide an insight on the acute care of patients with t-SCI.

RECENT FINDINGS

Multiple studies show that there appears to be a beneficial effect on neurological recovery of early surgical decompression within 24 h after trauma. Currently, the impact of ultra-early surgery is less clear as well as lacking evidence for the most optimal surgical technique. Nevertheless, early surgery to decompress the spinal cord by whatever method can impact the occurrence for perioperative complications and potentially expedite rehabilitation. There are clinical and socioeconomic barriers in achieving timely and adequate surgical interventions for t-SCI.

SUMMARY

In this review, we provide an overview of the recent insights of surgical timing in t-SCI and the current barriers in acute t-SCI treatment.

Factors Delaying the Continuum of Care for the Management of Traumatic Brain Injury in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Considering the disproportionate burden of delayed traumatic brain injury (TBI) management in low- and middle-income countries (LMICs), there is pressing demand for investigations. Therefore, our study aims to evaluate factors delaying the continuum of care for the management of TBIs in LMICs.

METHODS

A systematic review was conducted with PubMed, Scopus, Google Scholar and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Observational studies with TBI patients in LMIC were included. The factors affecting management of TBI were extracted and analyzed descriptively.

RESULTS

A total of 55 articles were included consisting of 60,603 TBI cases from 18 LMICs. Road traffic accidents (58.7%) were the most common cause of injury. Among included studies, factors contributing to prehospital delays included a poor referral system and lack of an organized system of referral (14%), long travel distances (11%), inadequacy of emergency medical services (16.6%), and self-treatment practices (2.38%). For in-hospital delays, factors such as lack of trained physicians (10%), improper triage systems (20%), and absence of imaging protocols (10%), lack of in-house computed tomography scanners (35%), malfunctioning computed tomography scanners (10%), and a lack of invasive monitoring of intracranial pressure (5%), limited theater space (28%), lack of in-house neurosurgical facilities (28%), absence of in-house neurosurgeons (28%), and financial constraints (14%) were identified.

CONCLUSIONS

Several factors, both before and during hospitalization contribute to delays in the management of TBIs in LMICs. Strategically addressing these factors can help overcome delays and improve TBI management in LMICs.

An update on pediatric traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) remains the commonest neurological and neurosurgical cause of death and survivor disability among children and young adults. This review summarizes some of the important recent publications that have added to our understanding of the condition and advanced clinical practice.

METHODS

Targeted review of the literature on various aspects of paediatric TBI over the last 5 years.

RESULTS

Recent literature has provided new insights into the burden of paediatric TBI and patient outcome across geographical divides and the severity spectrum. Although CT scans remain a standard, rapid sequence MRI without sedation has been increasingly used in the frontline. Advanced MRI sequences are also being used to better understand pathology and to improve prognostication. Various initiatives in paediatric and adult TBI have contributed regionally and internationally to harmonising research efforts in mild and severe TBI. Emerging data on advanced brain monitoring from paediatric studies and extrapolated from adult studies continues to slowly advance our understanding of its role. There has been growing interest in non-invasive monitoring, although the clinical applications remain somewhat unclear. Contributions of the first large scale comparative effectiveness trial have advanced knowledge, especially for the use of hyperosmolar therapies and cerebrospinal fluid drainage in severe paediatric TBI. Finally, the growth of large and even global networks is a welcome development that addresses the limitations of small sample size and generalizability typical of single-centre studies.

CONCLUSION

Publications in recent years have contributed iteratively to progress in understanding paediatric TBI and how best to manage patients.

Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article

Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.

Mining the contribution of intensive care clinical course to outcome after traumatic brain injury

Existing methods to characterise the evolving condition of traumatic brain injury (TBI) patients in the intensive care unit (ICU) do not capture the context necessary for individualising treatment. Here, we integrate all heterogenous data stored in medical records (1166 pre-ICU and ICU variables) to model the individualised contribution of clinical course to 6-month functional outcome on the Glasgow Outcome Scale -Extended (GOSE). On a prospective cohort (n = 1550, 65 centres) of TBI patients, we train recurrent neural network models to map a token-embedded time series representation of all variables (including missing values) to an ordinal GOSE prognosis every 2 h. The full range of variables explains up to 52% (95% CI: 50-54%) of the ordinal variance in functional outcome. Up to 91% (95% CI: 90-91%) of this explanation is derived from pre-ICU and admission information (i.e., static variables). Information collected in the ICU (i.e., dynamic variables) increases explanation (by up to 5% [95% CI: 4-6%]), though not enough to counter poorer overall performance in longer-stay (>5.75 days) patients. Highest-contributing variables include physician-based prognoses, CT features, and markers of neurological function. Whilst static information currently accounts for the majority of functional outcome explanation after TBI, data-driven analysis highlights investigative avenues to improve the dynamic characterisation of longer-stay patients. Moreover, our modelling strategy proves useful for converting large patient records into interpretable time series with missing data integration and minimal processing.

Surgical treatment of traumatic frontal hematoma: comparison of the endoscopic supraorbital approach with frontotemporal approach

Background

The objective of this study was to compare the efficacy, safety, and outcomes of the endoscopic supraorbital approach and frontotemporal approach for the treatment of traumatic frontal hematoma, with the aim of demonstrating the feasibility of the endoscopic supraorbital approach.

Methods

A total of 24 cases underwent hematoma evacuation, including 10 cases using the endoscopic supraorbital approach and 14 cases using the frontotemporal approach. Baseline demographic data, hematoma clearance rate, blood loss, postoperative complications, and 6-month outcomes were retrospectively analyzed.

Results

Both approaches effectively evacuated the hematoma, with hematoma clearance rates of 90.97 ± 10.23% in the endoscopic supraorbital group and 85.29 ± 16.15% in the frontotemporal approach group (p > 0.05). The supraorbital approach group demonstrated significantly shorter operation times compared to the frontotemporal approach group (116.50 ± 28.19 min vs. 193.29 ± 72.55 min, p < 0.05), as well as significantly less blood loss (55.00 ± 33.08 mL vs. 685.71 ± 840.20 mL, p < 0.05). There was no significant difference in the rate of postoperative complications between the two groups, and the majority of patients achieved favorable outcomes with a Glasgow Outcome Scale score of 4 or 5 in both groups.

Conclusion

Compared to the frontotemporal approach, the endoscopic supraorbital approach offers advantages such as shorter operation times, reduced blood loss, similar treatment effects, and comparable complication rates. Therefore, the endoscopic supraorbital approach may serve as a viable alternative for the treatment of traumatic frontal hematoma.

Pediatric Traumatic Brain Injury in Malawi: A Propensity-Weighted Analysis of Outcomes and Trends Over Time

BACKGROUND

Pediatric injuries contribute to substantial mortality and morbidity worldwide, particularly in sub-Saharan Africa. We aim to identify predictors of mortality and time trends for pediatric traumatic brain injuries (TBIs) in Malawi.

METHODS

We performed a propensity-matched analysis of data from the trauma registry at Kamuzu Central Hospital in Malawi from 2008 to 2021. All children ≤16 years of age were included. Demographic and clinical data were collected. Outcomes were compared between patients with and without head injuries.

RESULTS

A cohort of 54,878 patients was included, with 1755 having TBI. The mean ages of patients with and without TBI were 7.8 ± 7.8 years and 7.1 ± 4.5 years, respectively. The most common mechanism for patients with and without TBI was road traffic injury and falls, respectively (48.2% vs. 47.8%, P < 0.01). The crude mortality rate for the TBI cohort was 20.9% compared to 2.0% in the non-TBI cohort (P < 0.01). After propensity matching, patients with TBI had 4.7 higher odds of mortality (95% confidence interval 1.9-11.8). Over time, patients with TBI had an increasing predicted probability of mortality for all age categories, with the most significant increase among children younger than 1 year.

CONCLUSIONS

TBI confers a greater than 4-fold higher likelihood of mortality in this pediatric trauma population in a low-resource setting. These trends have worsened over time.

Assessment of Factors Associated With Mental Well-Being Among Chinese Youths at Individual, School, and Province Levels

Importance

Although rapid urbanization in China provided improved economic prosperity and educational opportunities, it was associated with increased internalizing and externalizing problems among youths, with negative outcomes for mental well-being. Previous studies suggested that factors in individual, school, and regional levels were associated with mental well-being, and comprehensively examining these factors may provide evidence for policies for improving youth mental health.

Objective

To investigate factors associated with mental well-being at individual, school, and province levels among Chinese youths.

Design, Setting, and Participants

This cross-sectional study analyzed nationally representative data collected December 1, 2021, to January 1, 2022, from schools in China. Among 435 schools, 144 institutions had primary school students, 107 institutions had middle school students, 95 institutions had primary and middle school students, and 89 institutions had high school students. A total of 398 520 students were included.

Exposures

Characteristics at individual, school, and province levels.

Main outcomes and measures

The main outcome was mental well-being, assessed by the Short Warwick-Edinburgh Mental Well-being Scale. Linear mixed-effects models were used to investigate individual, school, and regional disparities in mental well-being among youths.

Results

There were 398 520 participants (194 460 females [48.80%]; mean [SD; range] age, 13.78 [2.40; 9-20] years). At the school level, 352 443 students (88.44%) were in public school and 291 354 students (73.11%) were in urban schools. Drinking (coefficient = -1.08; 95% CI, -1.12 to -1.05; P < .001), smoking (coefficient = -0.89; 95% CI, -0.96 to -0.83; P < .001), and increased age (coefficient per 1-year increase in age = -0.02; 95% CI, -0.03 to -0.01; P < .001) were associated with worse mental well-being. Male sex (coefficient = 1.01; 95% CI, 0.98 to 1.04; P < .001), being in a 1-child family (coefficient = 0.17; 95% CI, 0.13 to 0.20; P < .001), being in the Han group (coefficient vs other ethnic groups = 0.20; 95% CI, 0.14 to 0.26; P < .001), a higher frequency and coverage of psychological courses (eg, ≥2/wk for all students vs none: coefficient = 1.02; 95% CI, 0.36 to 1.69; P = .003), and a higher level of self-rated popularity in school (coefficient per 1-unit increase in score = 0.89; 95% CI, 0.88 to 0.89; P < .001) were associated with improved mental well-being. However, age (eg, age and 1 courses/2 wk for all students: coefficient per 1-year increase in age = -0.047; 95% CI, -0.089 to -0.005; P = .03) and sex (eg, female sex and ≥2 courses/wk for some students: coefficient = -0.184; 95% CI, -0.323 to -0.046; P = .009) had interactions with the association between psychological courses and mental well-being.

Conclusions and relevance

This study found that social disparities in mental well-being existed and that various factors at different levels were associated with mental well-being among Chinese youths. These findings suggest that public mental health programs may be recommended for associated improvements in regional disparities in mental health resources.

An international, prospective observational study on traumatic brain injury epidemiology study protocol: GEO-TBI: Incidence

Background

The epidemiology of traumatic brain injury (TBI) is unclear - it is estimated to affect 27-69 million individuals yearly with the bulk of the TBI burden in low-to-middle income countries (LMICs). Research has highlighted significant between-hospital variability in TBI outcomes following emergency surgery, but the overall incidence and epidemiology of TBI remains unclear. To address this need, we established the Global Epidemiology and Outcomes following Traumatic Brain Injury (GEO-TBI) registry, enabling recording of all TBI cases requiring admission irrespective of surgical treatment.

Objective

The GEO-TBI: Incidence study aims to describe TBI epidemiology and outcomes according to development indices, and to highlight best practices to facilitate further comparative research.

Design

Multi-centre, international, registry-based, prospective cohort study.

Subjects

Any unit managing TBI and participating in the GEO-TBI registry will be eligible to join the study. Each unit will select a 90-day study period. All TBI patients meeting the registry inclusion criteria (neurosurgical/ICU admission or neurosurgical operation) during the selected study period will be included in the GEO-TBI: Incidence.

Methods

All units will form a study team, that will gain local approval, identify eligible patients and input data. Data will be collected via the secure registry platform and validated after collection. Identifiers may be collected if required for local utility in accordance with the GEO-TBI protocol.

Data

Data related to initial presentation, interventions and short-term outcomes will be collected in line with the GEO-TBI core dataset, developed following consensus from an iterative survey and feedback process. Patient demographics, injury details, timing and nature of interventions and post-injury care will be collected alongside associated complications. The primary outcome measures for the study will be the Glasgow Outcome at Discharge Scale (GODS) and 14-day mortality. Secondary outcome measures will be mortality and extended Glasgow Outcome Scale (GOSE) at the most recent follow-up timepoint.

Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma

BACKGROUND

Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear.

METHODS

We conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L).

RESULTS

A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P = 0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group.

CONCLUSIONS

Among patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group. (Funded by the National Institute for Health and Care Research; RESCUE-ASDH ISRCTN Registry number, ISRCTN87370545.).

Impact of a Femoral Fracture on Outcome after Traumatic Brain Injury-A Matched-Pair Analysis of the TraumaRegister DGU®

Traumatic brain injury (TBI) is the leading cause of death and disability in polytrauma and is often accompanied by concomitant injuries. We conducted a retrospective matched-pair analysis of data from a 10-year period from the multicenter database TraumaRegister DGU^® to analyze the impact of a concomitant femoral fracture on the outcome of TBI patients. A total of 4508 patients with moderate to critical TBI were included and matched by severity of TBI, American Society of Anesthesiologists (ASA) risk classification, initial Glasgow Coma Scale (GCS), age, and sex. Patients who suffered combined TBI and femoral fracture showed increased mortality and worse outcome at the time of discharge, a higher chance of multi-organ failure, and a rate of neurosurgical intervention. Especially those with moderate TBI showed enhanced in-hospital mortality when presenting with a concomitant femoral fracture (p = 0.037). The choice of fracture treatment (damage control orthopedics vs. early total care) did not impact mortality. In summary, patients with combined TBI and femoral fracture have higher mortality, more in-hospital complications, an increased need for neurosurgical intervention, and inferior outcome compared to patients with TBI solely. More investigations are needed to decipher the pathophysiological consequences of a long-bone fracture on the outcome after TBI.

Akkermansia muciniphila-Nlrp3 is involved in the neuroprotection of phosphoglycerate mutase 5 deficiency in traumatic brain injury mice

Introduction

Gut-microbiota-brain axis is a potential treatment to decrease the risk of chronic traumatic encephalopathy following traumatic brain injury (TBI). Phosphoglycerate mutase 5 (PGAM5), a mitochondrial serine/threonine protein phosphatase, resides in mitochondrial membrane and regulates mitochondrial homeostasis and metabolism. Mitochondria mediates intestinal barrier and gut microbiome.

Objectives

This study investigated the association between PGAM5 and gut microbiota in mice with TBI.

Methods

The controlled cortical impact injury was established in mice with genetically-ablated Pgam5 (Pgam5^-/-) or wild type, and WT male mice were treated with fecal microbiota transplantation (FMT) from male Pgam5^-/- mice or Akkermansia muciniphila (A. muciniphila). Then the gut microbiota abundance, blood metabolites, neurological function, and nerve injury were detected.

Results

Treated with antibiotics for suppressing gut microbiota in Pgam5^-/- mice partially relieved the role of Pgam5 deficiency in the improvement of initial inflammatory factors and motor dysfunction post-TBI. Pgam5 knockout exhibited an increased abundance of A. muciniphila in mice. FMT from male Pgam5^-/- mice enabled better maintenance of amino acid metabolism and peripherial environment than that in TBI-vehicle mice, which suppressed neuroinflammation and improved neurological deficits, and A. muciniphila was negatively associated with intestinal mucosal injury and neuroinflammation post-TBI. Moreover, A. muciniphila treatment ameliorated neuroinflammation and nerve injury by regulating Nlrp3 inflammasome activation in cerebral cortex with TBI.

Conclusion

Thus, the present study provides evidence that Pgam5 is involved in gut microbiota-mediated neuroinflammation and nerve injury, with A. muciniphila-Nlrp3 contributing to peripheral effects.

Update on Pediatric Mild Traumatic Brain Injury in Rural and Underserved Regions: A Global Perspective

BACKGROUND

Mild traumatic brain injury (MTBI) causes morbidity and disability worldwide. Pediatric patients are uniquely vulnerable due to developmental and psychosocial factors. Reduced healthcare access in rural/underserved communities impair management and outcome. A knowledge update relevant to current gaps in care is critically needed to develop targeted solutions.

METHODS

The National Library of Medicine PubMed database was queried using comprehensive search terms (("mild traumatic brain injury" or "concussion") and ("rural" or "low-income" or "underserved") and ("pediatric" or "child/children")) in the title, abstract, and Medical Subject Headings through December 2022. Fifteen articles on rural/underserved pediatric MTBI/concussion not covered in prior reviews were examined and organized into four topical categories: epidemiology, care practices, socioeconomic factors, and telehealth.

RESULTS

Incidences are higher for Individuals in rural regions, minorities, and those aged 0-4 years compared to their counterparts, and are increasing over time. Rural healthcare utilization rates generally exceed urban rates, and favor emergency departments (vs. primary care) for initial injury assessment. Management guidelines require customization to resource-constrained settings for implementation and adoption. Decreased community recognition of the seriousness of injury is a consensus challenge to care provision by clinicians. Low parental education and income were correlated with decreased MTBI knowledge and worse outcome. Telehealth protocols for triage/consultation and rehabilitation were feasible in improving care delivery to rural and remote settings.

CONCLUSIONS

Pediatric MTBI/concussion patients in rural/underserved regions experience increased risks of injury, geographic and financial healthcare barriers, and poorer outcomes. Globally, under-reporting of injury has hindered epidemiological understanding. Ongoing MTBI education should be implemented for rural caregivers, schools, and low-income populations to improve community awareness. Telehealth can improve care delivery across acuity settings, and warrants judicious inclusion in triage and treatment protocols.

Assessing the impact of neurosurgery and neuroanatomy simulation using 3D non-cadaveric models amongst selected African medical students

Background

Laboratory dissections are essential to acquire practical skills to perform neurosurgical procedures. Despite being traditionally done on cadavers, they are often unavailable and suffer from cultural barriers in the African context. Non-cadaveric UpSurgeOn neurosurgery models have been developed to bridge this barrier, providing an almost similar experience with the human body. This study aimed to assess the impact of the UpSurgeOn hands-on-touch non-cadaver model training amongst selected Cameroon medical students.

Methods

An anonymous 35-item questionnaire was distributed online using Google drive systems to medical students who attended UpSurgeOn's hands-on-touch non-cadaver model training course. These questions aimed to capture data on previous experience with neuroanatomy and neurosurgery practicals and the perception, attitudes, and impact of the UpSurgeOn neurosurgery tool.

Results

Eighty-six students completed the survey. The mean age was 21.2 ± 1.868 years, 61.6% were males with 62.8% of respondents being medical students in preclinical years. Before the training, 29.4% had a fair knowledge of neuroanatomy. Textbooks and Youtube videos were the main sources of neuroanatomy and neurosurgery knowledge for more than half of the respondents. Up to 91.5% had no prior exposure to a neuroanatomy/neurosurgery cadaver laboratory dissection, and 22.6% and 17.6% had witnessed and performed at least one craniotomy before, respectively. There were 11.1%, 15.5%, and 31.3% of our respondents who had used a surgical microscope, a neurosurgical instrument, and the UpSurgeOn Neurosurgery tool before, respectively. The majority perceived the UpSurgeOn tool easy to use and felt they needed to learn just a few things before getting going with the box. Most thought of increasing the use of the UpSurgeOn Box and saw the need to be part of the training curriculum. Finally, the majority felt this tool helped to increase familiarity and acquire neurosurgical skills, and to develop the orientation skills needed during neurosurgical approaches.

Conclusion

Undergraduate exposure to traditional neurosurgery/neuroanatomy labs is limited in Cameroon. Neurosurgery/neuroanatomy practical skills are gained essentially using non-practical means. Most students found the UpSurgeOn tool user-friendly, saw the need to incorporate it as part of their training, and perceived it to be essential in getting acquainted with neurosurgical skills.

Social Media for Global Neurosurgery. Benefits and limitations of a groundbreaking approach to communication and education

Introduction

Social media have become ubiquitous and their role in medicine is quickly growing. They provide an open platform by which members share educational material, clinical experiences, and collaborate with educational equity.

Research question

To characterize the role of social media in neurosurgery, we analyzed metrics of the largest neurosurgical group (Neurosurgery Cocktail), collected relevant data about activities, impact and risks of this groundbreaking technology.

Material and methods

We extracted Facebook metrics from 60-day time sample, including users demographics and other platform-specific values such as active members and number of posts within 60 days. A quality assessment of the posted material (clinical case reports and second opinions) was obtained establishing four main quality-criteria: privacy violation; quality of imaging; clinical and follow up data.

Results

By December 2022, the group included 29.524 members (79.8% male), most (29%) between 35 and 44 years of age. Over 100 countries were represented. A total of 787 posts were published in 60 days with an average of 12.7 per day. In 173 clinical cases presented through the platform, some issue with privacy was recorded in 50.9%. The imaging was considered insufficient in 39.3%, clinical data in 53.8%; follow up data were missing in 60.7%.

Discussion and conclusion

The study provided a quantitative evaluation of impact, flaws and limitations of social medial for healthcare. Flaws were mostly data breach and insufficient quality of case reports. There are actions to correct these flaws that can be easily taken to provide a greater credibility and efficacy to the system.

Towards Improved Organizational Governance of Neurotrauma Surveillance Comment on "Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries"

Neurotrauma surveillance data on burden and severity of disease serves as a tool to define legislations, guide high-yield risk-specific prevention, and evaluate and monitor management strategies for adequate resource allocation. In this scoping review, Barthélemy and colleagues demonstrate the gap in neurotrauma surveillance in low- and middle-income countries (LMICs) and suggest strategies for governance in neurotrauma surveillance. We underline state accountability as well as the need for the close integration of academic and tertiary care clinical practitioners and policy-makers in addressing the public health crisis caused by neurotrauma. Additionally, multiple sources for surveillance must be included, especially in communities where victims may remain without access to formal healthcare. Finally, we offer insights into possible ways of increasing the visibility of neurotrauma on political agendas.

Improved strategy for post-traumatic hydrocephalus following decompressive craniectomy: Experience of a single center

Background

Patients with head trauma may develop hydrocephalus after decompressive craniectomy. Many studies have referred one-stage cranioplasty (CP) and ventriculoperitoneal shunt (VPS) was applied to treat cranial defect with post-traumatic hydrocephalus (PTH), but the safety and efficiency of the procedure remain controversial.

Methods

This is a retrospective cohort study including 70 patients of PTH following decompressive craniectomy who underwent simultaneous (50) and separated (20) procedures of cranioplasty and VPS from March 2014 to March 2021 at the authors' institution with at least 30 days of follow-up. Patient characteristics, clinical findings, and complications were collected and analyzed.

Results

Fifty patients with PTH underwent improved simultaneous procedures and 20 patients underwent staged surgeries. Among the cases, the overall complication rate was 22.86%. Complications suffered by patients who underwent one-stage procedure of CP and VPS did not differ significantly, compared with patients in the group of staged procedures (22% vs. 25%, p = 0.763). The significant difference was not observed in the two groups, regarding the complications of subdural/epidural fluid collection (4%/6% vs. 0/2%, p = 1.000/1.000), epidural hemorrhage (6% vs. 4%, p = 0.942), dysfunction of shunting system (0 vs. 2%, p = 0.286), postoperative seizure (8% vs. 4%, p = 1.000), and reoperation case (0 vs. 2%, p = 0.286). No case of subdural hemorrhage, incision/intracranial/abdominal infection, shunting system dysfunction, or reoperation was observed in the group of simultaneous procedure. Complications including subdural/epidural fluid collection, subdural hemorrhage, and incision/intracranial infection were not shown in the case series of the staged procedure group.

Conclusion

The improved simultaneous procedure of cranioplasty and VPS is effective and safe to treat cranial defect and post-traumatic hydrocephalus with low risk of complications.

Traumatic Brain Injuries: Comprehensive Management of Complex Clinical Scenarios

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Demographics, Causes, and Outcome of Traumatic Brain Injury among Trauma Cases in Cameroon: A Multi-Center Five Year's Retrospective Study

Traumatic brain injury (TBI) is a huge public health challenge worldwide. Epidemiological monitoring is important to inform healthcare policy. We aimed at determining the prevalence, outcome, and causes of TBI in Cameroon by conducting a 5-year retrospective study in three referral trauma centers. Data on demographics, causes, injury mechanisms, clinical aspects, and discharge status were recorded. Comparisons between two categorical variables were done using Pearson's chi-square test or Fisher's exact test. A total of 6248 cases of TBI were identified of 18,151 trauma cases, yielding a prevalence of 34%. The number of TBI cases increased across the years (915 in 2016, 1406 in 2020). Demographic data and causes of TBI were available for 6248 subjects and detailed data on clinical characteristics on 2178 subjects. Median age was 30.0 (24.0, 41.0) years. Males were more affected (80%). Road traffic incidents (RTIs; 75%) was the main cause of TBI, with professional bike riders being more affected (17%). Computed tomography (CT) imaging was performed in 67.7% of cases. Of the 597 (27.4%) cases who did not undergo neuroimaging, 311 (52.1%) did not have neuroimaging performed because of financial constraints, among which 7% were severe TBI cases. A total of 341 (19.6%) patients were discharged against medical advice, of which 83% had financial limitations. Mortality was 10.3% (225 of 2178) in the overall population, but disproportionately high in patients with severe TBI (55%) compared to those in high-income settings (27%). TBI occurrence is high in Cameroon, and RTIs are the main causes. Disparities in care provision were identified as attributable to financial constraints regarding CT scanning and continuation of care. The data presented can inform preventive interventions to improve care provision and transport policies. Implementation of a universal health insurance may be expected to improve hospital care and reduce the adverse effects of TBI among Cameroonians.

Traumatic brain injury: progress and challenges in prevention, clinical care, and research

Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research.

In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents.

Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery.

The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition.

Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers.

In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI.

Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation.

Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority.

This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.

Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept

Objectives

Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH).

Materials and Methods

A scoping review was conducted on Medline database from inception to September 2021.

Results

The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D).

Conclusion

This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.

Second- and Third-Tier Therapies for Severe Traumatic Brain Injury

Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.

Global Neurosurgery in the Context of Global Public Health Practice-A Literature Review of Case Studies

Neurosurgical conditions are a substantial contributor to surgical burden worldwide, with low- and middle-income countries carrying a disproportionately large part. Policy initiatives such as the National Surgical, Obstetrics and Anesthesia Plans and Comprehensive Policy Recommendations for the Management of Spina Bifida and Hydrocephalus in Low-and-Middle-Income countries have highlighted the need for an intersectoral approach, not just at the hospital level but on a large scale encompassing national public health strategies. This article aims to show through case studies how addressing this surgical burden is not limited to the clinical context but extends to public health strategies as well. For example, vitamin B₁₂ and folic acid are micronutrients that, if not at adequate levels, can result in debilitating neurosurgical conditions. In Ethiopia, through coalesced efforts between neurosurgeons and policy makers, the government has made strides in implementing food fortification programs at a national level to address the neurosurgical burden. Traumatic brain injuries (TBIs) are another neurosurgical burden that unevenly affects LMICs. Countries such as Colombia and India have shown the importance of legislation and enforcement, coupled with robust data collection and auditing systems; strong academic advocacy of neurosurgeons can drastically reduce TBIs. Despite the importance of public health efforts in addressing neurosurgical conditions, there is a lack of neurosurgeon involvement in public health and lack of integration of neurosurgical burden in national health planning systems. It is imperative that neurosurgeons advocate for and are included in aspects of public health policy. Neurosurgery does not stop within the bounds of the hospital, and neither should the role of a neurosurgeon.