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Solomou G, Sunny J, Mohan M, Hossain I, Kolias AG, Hutchinson PJ. Decompressive craniectomy in trauma: What you need to know. J Trauma Acute Care Surg 2024; 97:490-496. [PMID: 39137371 DOI: 10.1097/ta.0000000000004357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
ABSTRACT Decompressive craniectomy (DC) is a surgical procedure in which a large section of the skull is removed, and the underlying dura mater is opened widely. After evacuating a traumatic acute subdural hematoma, a primary DC is typically performed if the brain is bulging or if brain swelling is expected over the next several days. However, a recent randomized trial found similar 12-month outcomes when primary DC was compared with craniotomy for acute subdural hematoma. Secondary removal of the bone flap was performed in 9% of the craniotomy group, but more wound complications occurred in the craniectomy group. Two further multicenter trials found that, whereas early neuroprotective bifrontal DC for mild to moderate intracranial hypertension is not superior to medical management, DC as a last-tier therapy for refractory intracranial hypertension leads to reduced mortality. Patients undergoing secondary last-tier DC are more likely to improve over time than those in the standard medical management group. The overall conclusion from the most up-to-date evidence is that secondary DC has a role in the management of intracranial hypertension following traumatic brain injury but is not a panacea. Therefore, the decision to offer this operation should be made on a case-by-case basis. Following DC, cranioplasty is warranted but not always feasible, especially in low- and middle-income countries. Consequently, a decompressive craniotomy, where the bone flap is allowed to "hinge" or "float," is sometimes used. Decompressive craniotomy is also an option in a subgroup of traumatic brain injury patients undergoing primary surgical evacuation when the brain is neither bulging nor relaxed. However, a high-quality randomized controlled trial is needed to delineate the specific indications and the type of decompressive craniotomy in appropriate patients.
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Affiliation(s)
- Georgios Solomou
- From the Division of Neurosurgery, Department of Clinical Neurosciences (G.S., J.S., M.M., I.H., A.G.K. P.J.H.), Addenbrooke's Hospital, University of Cambridge, Cambridge; National Hospital for Neurology and Neurosurgery (J.S.), London, United Kingdom; and Neurocenter (I.H.), Department of Neurosurgery, Turku University Hospital, Turku, Finland
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Khan MH, Fatima M, Abid SF, Faisal H, Ahmed R, Rashid AH, Amir S, Kashif TB, Syeda AZ, Naqi SA. Comparison of Decompressive Craniectomy Versus Craniotomy for Evacuation of Subdural Hemorrhage: A Systematic Review and Meta-Analysis. J Surg Res 2024; 302:593-605. [PMID: 39181026 DOI: 10.1016/j.jss.2024.07.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/23/2024] [Accepted: 07/27/2024] [Indexed: 08/27/2024]
Abstract
INTRODUCTION Acute subdural hemorrhage (ASDH) from traumatic brain injury is a life-threatening situation, often requiring surgical intervention. This meta-analysis is done to update the literature regarding the choice of procedure for the treatment of ASDH. METHODS PubMed, Scopus, and Cochrane were searched from the year 2000 up to September 2023. Randomized controlled trials and observational studies were included. The odds ratio with 95% confidence interval (CI) mean difference and standardized mean difference were calculated for dichotomous and continuous outcomes, respectively. RESULTS A total of 14 studies comprising 4686 patients were included in the analysis. Pooled Glasgow Outcome Scale/Extended Glasgow Outcome Scale scores were compared based on their means, with the craniotomy (CO) group having better mean scores than decompressive craniectomy (DC) (standardized mean difference -0.37, 95% CI -0.68 to -0.06, P = 0.02). The risk for poor outcomes was statistically greater in the DC group compared to the CO group (1.32, 95% CI 1.05-1.66, P value = 0.02). There were fewer residual subdural hematoma cases in the DC group as compared to CO (odds ratio 0.40, 95% CI 0.22-0.73, P value < 0.005). CONCLUSIONS Our meta-analysis showed that the ASDH patients had better functional outcomes when treated with CO as compared to DC. However, there were fewer odds of residual subdural hematoma with DC.
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Affiliation(s)
| | - Maurish Fatima
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | - Syeda Fatima Abid
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | - Hashim Faisal
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | - Roshaan Ahmed
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | | | - Saim Amir
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | - Talha Bin Kashif
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
| | | | - Syed Asghar Naqi
- Department of Surgery, King Edward Medical University, Lahore, Pakistan
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Hiskens MI, Schneiders AG, Fenning AS. Selective COX-2 Inhibitors as Neuroprotective Agents in Traumatic Brain Injury. Biomedicines 2024; 12:1930. [PMID: 39200394 PMCID: PMC11352079 DOI: 10.3390/biomedicines12081930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/31/2024] [Accepted: 08/21/2024] [Indexed: 09/02/2024] Open
Abstract
Traumatic brain injury (TBI) is a significant contributor to mortality and morbidity in people, both young and old. There are currently no approved therapeutic interventions for TBI. Following TBI, cyclooxygenase (COX) enzymes generate prostaglandins and reactive oxygen species that perpetuate inflammation, with COX-1 and COX-2 isoforms providing differing responses. Selective COX-2 inhibitors have shown potential as neuroprotective agents. Results from animal models of TBI suggest potential treatment through the alleviation of secondary injury mechanisms involving neuroinflammation and neuronal cell death. Additionally, early clinical trials have shown that the use of celecoxib improves patient mortality and outcomes. This review aims to summarize the therapeutic effects of COX-2 inhibitors observed in TBI animal models, highlighting pertinent studies elucidating molecular pathways and expounding upon their mechanistic actions. We then investigated the current state of evidence for the utilization of COX-2 inhibitors for TBI patients.
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Affiliation(s)
- Matthew I. Hiskens
- Mackay Institute of Research and Innovation, Mackay Hospital and Health Service, Mackay, QLD 4740, Australia
| | - Anthony G. Schneiders
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, QLD 4701, Australia (A.S.F.)
| | - Andrew S. Fenning
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, QLD 4701, Australia (A.S.F.)
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Dolmans RGF, Barber J, Foreman B, Temkin NR, Okwonko DO, Robertson CS, Manley GT, Rosenthal ES. Sedation Intensity in Patients with Moderate to Severe Traumatic Brain Injury in the Intensive Care Unit: A TRACK-TBI Cohort Study. Neurocrit Care 2024:10.1007/s12028-024-02054-7. [PMID: 39138718 DOI: 10.1007/s12028-024-02054-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/21/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Interventions to reduce intracranial pressure (ICP) in patients with traumatic brain injury (TBI) are multimodal but variable, including sedation-dosing strategies. This article quantifies the different sedation intensities administered in patients with moderate to severe TBI (msTBI) using the therapy intensity level (TIL) across different intensive care units (ICUs), including the use of additional ICP-lowering therapies. METHODS Within the prospective Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, we performed a retrospective analysis of adult patients with msTBI admitted to an ICU for a least 5 days from seven US level 1 trauma centers who received invasive ICP monitoring and intravenous sedation. Sedation intensity was classified prospectively as one of three ordinal levels as part of the validated TIL score, which were collected at least once a day. RESULTS A total of 127 patients met inclusion criteria (mean age 41.6 ± 17.7 years; 20% female). The median Injury Severity Score was 27 (interquartile range 17-33), with a median admission Glasgow Coma Score of 3 (interquartile range 3-7); 104 patients had severe TBI (82%), and 23 patients had moderate TBI (18%). The sedation intensity score was highest on the first ICU day (2.69 ± 1.78), independent of patient severity. Time to reaching each sedation intensity level varied by site. Sedation level I was reached within 24 h for all sites, but sedation levels II and III were reached variably between days 1 and 3. Sedation level III was never reached by two of seven sites. The total TIL score was highest on the first ICU day, with a modest decrease for each subsequent ICU day, but there was high site-specific practice-pattern variation. CONCLUSIONS Intensity of sedation and other therapies for elevated ICP for patients with msTBI demonstrate large practice-pattern variation across level 1 trauma centers within the TRACK-TBI cohort study, independent of patient severity. Optimizing sedation strategies using patient-specific physiologic and pathoanatomic information may optimize patient outcomes.
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Affiliation(s)
- Rianne G F Dolmans
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati and, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - David O Okwonko
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Geoffrey T Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
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Li H, Yao Y, Jiang Y, Su Y, Wang H, Zhu C, Gan W. Comparison of craniotomy and decompressive craniectomy for acute subdural hematoma: a meta-analysis of comparative study. Int J Surg 2024; 110:5101-5111. [PMID: 38884600 PMCID: PMC11326010 DOI: 10.1097/js9.0000000000001590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/25/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Acute subdural hematoma (ASDH) necessitates urgent surgical intervention. Craniotomy (CO) and decompressive craniectomy (DC) are the two main surgical procedures for ASDH evacuation. This meta-analysis is to compare the clinical outcomes between the CO and DC procedures. MATERIALS AND METHODS The authors performed a meta-analysis according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA, Supplemental Digital Content 1, http://links.lww.com/JS9/C513 , Supplemental Digital Content 2, http://links.lww.com/JS9/C514 ) Statement protocol and assessing the methodological quality of systematic reviews (AMSTAR) (Supplemental Digital Content 3, http://links.lww.com/JS9/C515 ) guideline. The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched. Comparative studies reporting the outcomes of the CO and DC procedures in patients with ASDH were included. RESULTS A total of 15 articles with 4853 patients [2531 (52.2%) receiving CO and 2322 (47.8%) receiving DC] were included in this meta-analysis. DC was associated with higher mortality [31.5 vs. 40.6%, odds ratio (OR)=0.58, 95% CI: 0.43-0.77] and rate of patients with poorer neurological outcomes (54.3 vs. 72.7%; OR=0.43, 95% CI: 0.28-0.67) compared to CO. The meta-regression model identified the comparability of preoperative severity as the only potential source of heterogeneity. When the preoperative severity was comparable between the two procedures, the mortality (CO 35.5 vs. DC 38.1%, OR=0.80, 95% CI: 0.62-1.02) and the proportion of patients with poorer neurological outcomes (CO 64.8 vs. DC 66.0%; OR=0.82, 95% CI: 0.57-1.16) were both similar. Reoperation rates were similar between the two procedures (CO 16.1 vs. DC 16.0%; OR=0.95, 95% CI: 0.61-1.48). CONCLUSION Our meta-analysis reveals that DC is associated with higher mortality and poorer neurological outcomes in ASDH compared to CO. Notably, this difference in outcomes might be driven by baseline patient severity, as the significance of surgical choice diminishes after adjusting for this factor. Our findings challenge previous opinions regarding the superiority of CO over DC and underscore the importance of considering patient-specific characteristics when making surgical decisions. This insight offers guidance for surgeons in making decisions tailored to the specific conditions of their patients.
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Affiliation(s)
- Hua Li
- Department of Orthopedics, Beijing Jishuitan Hospital
| | - Yuqiang Yao
- Department of Neurosurgery, Beijing Jishuitan Hospital, Beijing
| | - Yuwen Jiang
- Department of Traumatology, Zhuhai People's Hospital, Zhuhai, Guangdong
| | - Yibing Su
- Department of Neurosurgery, Beijing Jishuitan Hospital, Beijing
| | - Hanbin Wang
- Department of Neurosurgery, Beijing Jishuitan Hospital, Beijing
| | - Can Zhu
- Second Department of Clinical Medicine, Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Wenyi Gan
- Department of Traumatology, Zhuhai People's Hospital, Zhuhai, Guangdong
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Singh R, van Dijck J, van Essen T, Nix H, Vreeburg R, den Boogert H, de Ruiter G, Depreitere B, Peul W. The death of a neurotrauma trial lessons learned from the prematurely halted randomized evaluation of surgery in elderly with traumatic acute subdural hematoma (RESET-ASDH) trial. BRAIN & SPINE 2024; 4:102903. [PMID: 39185388 PMCID: PMC11342112 DOI: 10.1016/j.bas.2024.102903] [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: 04/25/2024] [Revised: 06/30/2024] [Accepted: 07/17/2024] [Indexed: 08/27/2024]
Abstract
Introduction Acute subdural hematoma (ASDH) due to traumatic brain injury (TBI) constitutes an increasing global health problem, especially in the elderly population. Treatment decisions on surgical versus conservative management pose a neurosurgical dilemma. Large practice variation exists between countries, hospitals, and individual neurosurgeons, illustrating the presence of 'clinical equipoise'. The RESET-ASDH trial aimed to address this dilemma but was terminated prematurely due to insufficient patient recruitment. Research question What factors may have contributed to the premature discontinuation of the RESET-ASDH trial? Materials and methods The RESET-ASDH was a multicenter randomized controlled trial (RCT) comparing functional outcome at 1 year after early surgery or an initial conservative treatment in elderly patients (≥65 years) with a traumatic ASDH. Logs of registry data, medical-ethical approval timelines and COVID-19 related research documents were analyzed. Furthermore, non-structured interviews with involved clinical research personnel were conducted. Results The concept of clinical equipoise was broadly misinterpreted by neurosurgeons as individual uncertainty, hampering patient recruitment. Also, the elderly target population complicated the inclusion process as elderly and their informal caregivers were hesitant to participate in our acute surgical trial. Moreover, the COVID-19 pandemic added additional hurdles like delayed medical-ethical approval, a decline in eligible patients and repeated trial halts during the peaks of the pandemic. Discussion and conclusion The premature termination of the RESET-ASDH study may have been related to the trial's methodology and target population with an additional impact of COVID-19. Future acute neurosurgical trials in elderly may consider these challenges to prevent premature trial termination.
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Affiliation(s)
- R.D. Singh
- University Neurosurgical Center Holland (UNCH), Leiden University Medical Center (LUMC), Haaglanden Medical Center (HMC) and Haga Teaching Hospital, Department of Neurosurgery, Leiden and The Hague, the Netherlands
| | - J.T.J.M. van Dijck
- University Neurosurgical Center Holland (UNCH), Leiden University Medical Center (LUMC), Haaglanden Medical Center (HMC) and Haga Teaching Hospital, Department of Neurosurgery, Leiden and The Hague, the Netherlands
| | - T.A. van Essen
- University Neurosurgical Center Holland (UNCH), Leiden University Medical Center (LUMC), Haaglanden Medical Center (HMC) and Haga Teaching Hospital, Department of Neurosurgery, Leiden and The Hague, the Netherlands
- Department of Surgery, Division of Neurosurgery, QEll Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - H.P. Nix
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - R.J.G. Vreeburg
- University Neurosurgical Center Holland (UNCH), Leiden University Medical Center (LUMC), Haaglanden Medical Center (HMC) and Haga Teaching Hospital, Department of Neurosurgery, Leiden and The Hague, the Netherlands
| | - H.F. den Boogert
- University Neurosurgical Center Holland (UNCH), Leiden University Medical Center (LUMC), Haaglanden Medical Center (HMC) and Haga Teaching Hospital, Department of Neurosurgery, Leiden and The Hague, the Netherlands
| | - G.C.W. de Ruiter
- University Neurosurgical Center Holland (UNCH), Leiden University Medical Center (LUMC), Haaglanden Medical Center (HMC) and Haga Teaching Hospital, Department of Neurosurgery, Leiden and The Hague, the Netherlands
| | - B. Depreitere
- University Hospital Leuven (UZ Leuven), Department of Neurosurgery, Leuven, Belgium
| | - W.C. Peul
- University Neurosurgical Center Holland (UNCH), Leiden University Medical Center (LUMC), Haaglanden Medical Center (HMC) and Haga Teaching Hospital, Department of Neurosurgery, Leiden and The Hague, the Netherlands
| | - RESET-ASDH participants and investigators1
- University Neurosurgical Center Holland (UNCH), Leiden University Medical Center (LUMC), Haaglanden Medical Center (HMC) and Haga Teaching Hospital, Department of Neurosurgery, Leiden and The Hague, the Netherlands
- Department of Surgery, Division of Neurosurgery, QEll Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- University Hospital Leuven (UZ Leuven), Department of Neurosurgery, Leuven, Belgium
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Kapapa T, Jesuthasan S, Schiller F, Schiller F, Woischneck D, Gräve S, Barth E, Mayer B, Oehmichen M, Pala A. Outcome after decompressive craniectomy in older adults after traumatic brain injury. Front Med (Lausanne) 2024; 11:1422040. [PMID: 39040896 PMCID: PMC11260794 DOI: 10.3389/fmed.2024.1422040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
Objective Globally, many societies are experiencing an increase in the number of older adults (>65 years). However, there has been a widening gap between the chronological and biological age of older adults which trend to a more active and social participating part of the society. Concurrently, the incidence of traumatic brain injury (TBI) is increasing globally. The aim of this study was to investigate the outcome after TBI and decompressive craniectomy (DC) in older adults compared with younger patients. Methods A retrospective, multi-centre, descriptive, observational study was conducted, including severe TBI patients who were treated with DC between 2005 and 2022. Outcome after discharge and 12 months was evaluated according to the Glasgow Outcome Scale (Sliding dichotomy based on three prognostic bands). Significance was established as p ≤ 0.05. Results A total of 223 patients were included. The majority (N = 158, 70.9%) survived TBI and DC at discharge. However, unfavourable outcome was predominant at discharge (88%) and after 12 months (67%). There was a difference in favour of younger patients (≤65 years) between the age groups at discharge (p = 0.006) and at 12 months (p < 0.001). A subgroup analysis of the older patients (66 to ≤74 vs. ≥75 years) did not reveal any significant differences. After 12 months, 64% of the older patients had a fatal outcome. Only 10% of those >65 years old had a good or very good outcome. 25% were depending on support in everyday activities. After 12 months, the age (OR 0.937, p = 0.007, CI 95%: 0.894-0.981; univariate) and performed cranioplasty (univariate and multivariate results) were influential factors for the dichotomized GOS. For unfavourable outcome after 12 months, the thresholds were calculated for age = 55.5 years (p < 0.001), time between trauma and surgery = 8.25 h (p = 0.671) and Glasgow Coma Scale (GCS) = 4 (p = 0.429). Conclusion Even under the current modern conditions of neuro-critical care, with significant advances in intensive care and rehabilitation medicine, the majority of patients >65 years of age following severe TBI and DC died or were dependent and usually required extensive support. This aspect should also be taken into account during decision making and counselling (inter-, intradisciplinary or with relatives) for a very mobile and active older section of society, together with the patient's will.
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Affiliation(s)
- Thomas Kapapa
- Neurosurgical Department, University Hospital Ulm, Ulm, Germany
| | | | | | | | | | - Stefanie Gräve
- Section Interdisciplinary Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Eberhard Barth
- Section Interdisciplinary Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | | | - Andrej Pala
- Neurosurgical Department, University Hospital Ulm, Ulm, Germany
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Nadeem A, Siddiqui T, Rais T, Munsab R, Habib A, Afridi EK, Shariq F. Comparing surgical outcomes: Craniotomy versus decompressive craniectomy in acute subdural hematoma - A systematic review and meta-analysis. World Neurosurg X 2024; 23:100368. [PMID: 38623315 PMCID: PMC11017056 DOI: 10.1016/j.wnsx.2024.100368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 03/20/2024] [Indexed: 04/17/2024] Open
Abstract
Introduction Acute subdural hematomas (SDH) pose a significant health risk, often resulting from traumatic head injuries. The choice between surgical interventions, craniotomy, and decompressive craniectomy, remains a subject of debate. This meta-analysis aims to compare outcomes and guide clinical decision-making. Methods Following PRISMA guidelines, a comprehensive literature search was conducted in databases such as Ovid Medline, PubMed, and Cochrane, up to December 2023. Selection criteria included studies comparing craniotomy and decompressive craniectomy for acute SDH. Data extraction utilized the Newcastle-Ottawa Quality Assessment Tool, and statistical analysis employed the random-effects model. Results The meta-analysis included 17 studies and 6848 patients. Craniotomy demonstrated a significant reduction in mortality rates (RR 0.80, 95% CI 0.73-0.89, P < 0.0001). GCS scores favored craniotomy for severe cases. GOS outcomes showed a trend favoring craniotomy, particularly in good recovery (RR 1.34, 95% CI 1.04-1.74, P = 0.03). Additional factors explored included co-existing sub-epidural hematoma, mydriasis, extracranial injuries, residual SDH, revision rates, and intracranial pressure. Conclusion The meta-analysis suggests that craniotomy may be a favorable surgical strategy for acute SDH, displaying a significant decrease in mortality rates and a lower risk of raised intracranial pressure. However, the nuanced nature of outcomes emphasizes the need for a tailored approach, considering broader clinical contexts. Future research should address limitations and provide a basis for well-informed clinical decision-making.
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Affiliation(s)
- Abdullah Nadeem
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Taruba Rais
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | - Rabbia Munsab
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | - Ashna Habib
- Dow University of Health Sciences, Mission Road, Karachi, Pakistan
| | | | - Fariha Shariq
- Karachi Medical and Dental College, Karachi, Pakistan
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Enomoto N, Matsuzaki K, Matsuda T, Yamaguchi T, Miyamoto T, Hanaoka M, Teshima N, Kageyama A, Satoh Y, Haboshi T, Korai M, Shimada K, Niki H, Satoh K, Takagi Y. Effectiveness of hinge craniotomy as an alternative to decompressive craniectomy for acute subdural hematoma. Acta Neurochir (Wien) 2024; 166:272. [PMID: 38888676 DOI: 10.1007/s00701-024-06167-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Acute subdural hematoma (ASDH) is a life-threatening condition, and hematoma removal is necessary as a lifesaving procedure when the intracranial pressure is highly elevated. However, whether decompressive craniectomy (DC) or conventional craniotomy (CC) is adequate remains unclear. Hinge craniotomy (HC) is a technique that provides expansion potential for decompression while retaining the bone flap. At our institution, HC is the first-line operation instead of DC for traumatic ASDH, and we present the surgical outcomes. METHODS From January 1, 2017, to December 31, 2022, 372 patients with traumatic ASDH were admitted to our institution, among whom 48 underwent hematoma evacuation during the acute phase. HC was performed in cases where brain swelling was observed intraoperatively. If brain swelling was not observed, CC was selected. DC was performed only when the brain was too swollen to allow replacement of the bone flap. We conducted a retrospective analysis of patient demographics, prognosis, and subsequent cranial procedures for each technique. RESULTS Of the 48 patients, 2 underwent DC, 23 underwent HC, and 23 underwent CC. The overall mortality rate was 20.8% (10/48) at discharge and 30.0% (12/40) at 6 months. The in-hospital mortality rates for DC, HC, and CC were 100% (2/2), 21.7% (5/23), and 13.0% (3/23), respectively. Primary brain injury was the cause of death in five patients whose brainstem function was lost immediately after surgery. No fatalities were attributed to the progression of postoperative brain herniation. In only one case, the cerebral contusion worsened after the initial surgery, leading to brain herniation and necessitating secondary DC. CONCLUSIONS The strategy of performing HC as the first-line operation for ASDH did not increase the mortality rate compared with past surgical reports and required secondary DC in only one case.
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Affiliation(s)
- Noriya Enomoto
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan.
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan.
| | - Kazuhito Matsuzaki
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Tomohiro Matsuda
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Tadashi Yamaguchi
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Takeshi Miyamoto
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Mami Hanaoka
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Natsumi Teshima
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Ayato Kageyama
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Yuichi Satoh
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Tatsuya Haboshi
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Masaaki Korai
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Kenji Shimada
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
| | - Hitoshi Niki
- Department of Neurology, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Koichi Satoh
- Department of Neurosurgery, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Tokushima, Japan
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Shoaib A, Hussain F, Khan M, Sohail A, Hasnain Panjwani M, Talal Ashraf M, Choudhary A. Comparative efficacy of craniotomy versus craniectomy in surgical management of acute subdural hematoma: A systematic review and meta-analysis. J Clin Neurosci 2024; 124:154-168. [PMID: 38718611 DOI: 10.1016/j.jocn.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Acute subdural hematoma (ASDH), a predominantly lethal neurosurgical emergency in the settings of traumatic brain injury, requires surgical evacuation of hematoma, via craniotomy or craniectomy. The clinical practices vary, with no consensus over the superiority of either procedure. AIM To evaluate whether craniotomy or craniectomy is the optimal approach for surgical evacuation of ASDH. METHODS After a comprehensive search of PubMed, Google Scholar, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) up to January 2024, to identify relevant studies, a meta-analysis was performed using a random-effects model, and risk ratios were calculated with 95% confidence intervals (CIs). For quality assessment, the Cochrane risk of bias tool and Newcastle-Ottawa Scale were applied. RESULTS Out of 2143 potentially relevant studies, 1875 were deemed suitable for screening. Eighteen studies were included in the systematic review. Thirteen studies, in which 1589 patients underwent craniotomy and 1452 patients underwent craniectomy, allowed meta-analysis. Pooled estimates showed that there was no significant correlation of mortality at 6 months (RR 1.14;95 % CI; 0.94-1.38 P = 0.18) and 12 months (RR 1.17; 95 % CI; 0.84-1.63 P = 0.36) with the two surgical modalities. A positive association was observed between improved functional outcomes at 6-months and craniotomy (RR 0.76; 95 % CI; 0.62-0.93 P = 0.008), however, no significant difference was observed between the two treatment groups at 12 months follow-up (RR 0.89; 95 % CI; 0.72-1.09 P = 0.26). Craniotomy reported a significantly higher proportion of patients discharged to home (RR 0.63; 95 % CI; 0.49-0.83 P = 0.0007), whereas incidence of residual subdural hematoma was significantly lower in the craniectomy group (RR 0.70; 95 % CI; 0.52-0.94 P = 0.02). CONCLUSION Craniectomy is associated with poor clinical outcomes. However, with long-term follow-up, no difference in mortality and functional outcomes is observed in either of the patient populations. On account of equivocal evidence regarding the efficacy of craniectomy over craniotomy in the realm of long-term outcomes, utmost preference shall be directed toward craniotomy as it is less invasive and associated with fewer complications.
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Affiliation(s)
- Areeba Shoaib
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan.
| | - Fakiha Hussain
- Department of Medicine, Liaquat College of Medicine and Dentistry, Karachi, Pakistan
| | - Maryam Khan
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Affan Sohail
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | | | - Anood Choudhary
- Department of Medicine, Karachi Medical and Dental College, Karachi, Pakistan.
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11
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Zhang S, Gao G, Liu W. Craniectomy versus craniotomy: What can we do for acute subdural hematoma? Aging Med (Milton) 2024; 7:276-278. [PMID: 38975314 PMCID: PMC11222726 DOI: 10.1002/agm2.12322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/11/2024] [Accepted: 05/29/2024] [Indexed: 07/09/2024] Open
Abstract
Compared with hematoma evacuation craniotomy, decompressive craniectomy has a higher incidence of intracranial complications and no outcome benefit over craniotomy, which gives surgeons a safer decision-making options during surgery.
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Affiliation(s)
- Shuo Zhang
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Guoyi Gao
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Weiming Liu
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
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12
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Gkantsinikoudis N, Monioudis P, Antoniades E, Tsitouras V, Magras I. Fatal postoperative tension pneumocephalus after acute subdural hematoma evacuation: a case report. Int J Neurosci 2024:1-6. [PMID: 38716712 DOI: 10.1080/00207454.2024.2352767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH). CASE PRESENTATION An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day. CONCLUSION TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.
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Affiliation(s)
- Nikolaos Gkantsinikoudis
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Monioudis
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elias Antoniades
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vassilios Tsitouras
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Magras
- Second Department of Neurosurgery, Ippokratio General Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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13
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Davis CK, Arruri V, Joshi P, Vemuganti R. Non-pharmacological interventions for traumatic brain injury. J Cereb Blood Flow Metab 2024; 44:641-659. [PMID: 38388365 PMCID: PMC11197135 DOI: 10.1177/0271678x241234770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024]
Abstract
Heterogeneity and variability of symptoms due to the type, site, age, sex, and severity of injury make each case of traumatic brain injury (TBI) unique. Considering this, a universal treatment strategy may not be fruitful in managing outcomes after TBI. Most of the pharmacological therapies for TBI aim at modifying a particular pathway or molecular process in the sequelae of secondary injury rather than a holistic approach. On the other hand, non-pharmacological interventions such as hypothermia, hyperbaric oxygen, preconditioning with dietary adaptations, exercise, environmental enrichment, deep brain stimulation, decompressive craniectomy, probiotic use, gene therapy, music therapy, and stem cell therapy can promote healing by modulating multiple neuroprotective mechanisms. In this review, we discussed the major non-pharmacological interventions that are being tested in animal models of TBI as well as in clinical trials. We evaluated the functional outcomes of various interventions with an emphasis on the links between molecular mechanisms and outcomes after TBI.
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Affiliation(s)
- Charles K Davis
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Vijay Arruri
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Pallavi Joshi
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
- Neuroscience Training Program, University of Wisconsin, Madison, WI, USA
| | - Raghu Vemuganti
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
- Neuroscience Training Program, University of Wisconsin, Madison, WI, USA
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
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14
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Shafique MA, Mustafa MS, Luke-Wold B, Kumar A, Rangwala BS, Abdullah M, Ali SMS, Iqbal J, Haseeb A. Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy. Acta Neurochir (Wien) 2024; 166:121. [PMID: 38436794 DOI: 10.1007/s00701-024-06013-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy. MATERIALS AND METHODS We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes. RESULTS We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04). CONCLUSION Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.
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Affiliation(s)
- Muhammad Ashir Shafique
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan.
| | - Muhammad Saqlain Mustafa
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Brandon Luke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Aashish Kumar
- Department of Neurosurgery, Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75010, Pakistan
| | - Burhanuddin Sohail Rangwala
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
| | - Muhammad Abdullah
- Department of Neurosurgery, Rai Medical College, Lahore Road, Sargodha City, 40100, Punjab, Pakistan
| | - Syed Muhammad Sinaan Ali
- Department of Neurosurgery, Liaquat National Hospital and Medical College, National Stadium Rd, Karachi, 74800, Pakistan
| | - Javed Iqbal
- Department of Neurosurgery, King Edward Medical University, Lahore, Pakistan
| | - Abdul Haseeb
- Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan
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15
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Ritter K, Somnuke P, Hu L, Griemert EV, Schäfer MKE. Current state of neuroprotective therapy using antibiotics in human traumatic brain injury and animal models. BMC Neurosci 2024; 25:10. [PMID: 38424488 PMCID: PMC10905838 DOI: 10.1186/s12868-024-00851-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
TBI is a leading cause of death and disability in young people and older adults worldwide. There is no gold standard treatment for TBI besides surgical interventions and symptomatic relief. Post-injury infections, such as lower respiratory tract and surgical site infections or meningitis are frequent complications following TBI. Whether the use of preventive and/or symptomatic antibiotic therapy improves patient mortality and outcome is an ongoing matter of debate. In contrast, results from animal models of TBI suggest translational perspectives and support the hypothesis that antibiotics, independent of their anti-microbial activity, alleviate secondary injury and improve neurological outcomes. These beneficial effects were largely attributed to the inhibition of neuroinflammation and neuronal cell death. In this review, we briefly outline current treatment options, including antibiotic therapy, for patients with TBI. We then summarize the therapeutic effects of the most commonly tested antibiotics in TBI animal models, highlight studies identifying molecular targets of antibiotics, and discuss similarities and differences in their mechanistic modes of action.
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Affiliation(s)
- Katharina Ritter
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
| | - Pawit Somnuke
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Lingjiao Hu
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
- Department of Gastroenterology, Nanxishan Hospital of Guangxi Zhuang Autonomous Region, Guilin, China
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany
| | - Michael K E Schäfer
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Langenbeckstraße 1 (Bld. 505), Mainz, 55131, Germany.
- Focus Program Translational Neurosciences (FTN, Johannes Gutenberg-University Mainz, Mainz, Germany.
- Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg- University Mainz, Mainz, Germany.
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16
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Maas AIR, Menon DK. Highlights in traumatic brain injury research in 2023. Lancet Neurol 2024; 23:15-17. [PMID: 38101885 DOI: 10.1016/s1474-4422(23)00458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem 2650, Belgium; Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium.
| | - David K Menon
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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17
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Adegeest CY, Ter Wengel PV, Peul WC. Traumatic spinal cord injury: acute phase treatment in critical care. Curr Opin Crit Care 2023; 29:659-665. [PMID: 37909371 DOI: 10.1097/mcc.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
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.
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Affiliation(s)
- Charlotte Y Adegeest
- University Neurosurgical Center Holland (UNCH), LUMC | HMC | HAGA, Leiden-The Hague, the Netherlands
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