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Huang W, Hua C, Guo Y, Gao W, Li Y, Zheng Y. Super resolution imaging reconstruction reveals that gold standard methods may not correctly conclude neural/brain functional recovery. Comput Med Imaging Graph 2023; 105:102198. [PMID: 36805708 DOI: 10.1016/j.compmedimag.2023.102198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 12/17/2022] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
The status of cerebral perfusion and its restoration level play a vital role in the prognosis and clinical decision making of many neurosurgical diseases. As such, gold standard methods including CT, MR and ICP monitoring, which can indicate and measure cerebral perfusion and restoration, have been widely adopted to evaluate whether or not a patient has recovered from neurofunctional disabilities. This robust combination of methods, however, is confronted with a growing number of contradictions in recent years due to its inability to measure the status of cerebral reperfusion in microvasculature level, even though this has been shown to determine neurofunctional restoration as well or even better. To this date, nevertheless, we have very limited imaging methods that could evaluate human cerebral microperfusion both safely and accurately under most neurosurgical conditions. We herein report a new method of acquiring a patient's cerebral microperfusion status noninvasively which could display the precise distribution of microvasculature in deep cerebral regions with a resolution of ∼30 µm, using everyday bed-side ultrasonography combined with a computerized super-resolution reconstruction algorithm. Using this imaging modality, we found that a patient's cerebral microperfusion might not be improved by some routine administrations even though the gold standard method had yielded the opposite conclusions. Our imaging modality retains the safe, portable feature of ordinary ultrasonography while possesses the extraordinary super-resolution nature, which enables an efficient, precise diagnosis of cerebral perfusion. Most importantly, the super resolution nature of this method may also facilitate early-stage evaluation of a patient's neurofunctional restoration level and avoid overoptimistic conclusions from conventional angiography or ICP monitoring.
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Affiliation(s)
- Weifeng Huang
- Department of Critical Care Medicine, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Hua
- Department of Ultrasound, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Center for Brain Science, Shanghai, China.
| | - Yan Guo
- Department of Neurosurgery, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenwei Gao
- Department of Neurosurgery, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingchuan Li
- Department of Critical Care Medicine, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Yuanyi Zheng
- Department of Ultrasound, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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2
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Zhang ZD, Zhao LY, Liu YR, Zhang JY, Xie SH, Lin YQ, Tang ZN, Fang HY, Yang Y, Li SZ, Liu JX, Sheng HS. Absorbable Artificial Dura Versus Nonabsorbable Artificial Dura in Decompressive Craniectomy for Severe Traumatic Brain Injury: A Retrospective Cohort Study in Two Centers. Front Surg 2022; 9:877038. [PMID: 35865039 PMCID: PMC9295144 DOI: 10.3389/fsurg.2022.877038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background Severe traumatic brain injury (TBI) patients usually need decompressive craniectomy (DC) to decrease intracranial pressure. Duraplasty is an important step in DC with various dura substitute choices. This study aims to compare absorbable dura with nonabsorbable dura in duraplasty for severe TBI patients. Methods One hundred and three severe TBI patients who underwent DC and dura repair were included in this study. Thirty-nine cases used absorbable artificial dura (DuraMax) and 64 cases used nonabsorbable artificial dura (NormalGEN). Postoperative complications, mortality and Karnofsky Performance Scale (KPS) score in one year were compared in both groups. Results Absorbable dura group had higher complication rates in transcalvarial cerebral herniation (TCH) (43.59% in absorbable dura group vs. 17.19% in nonabsorbable dura group, P = 0.003) and CSF leakage (15.38% in absorbable dura group vs. 1.56% in nonabsorbable dura group, P = 0.021). But severity of TCH described with hernial distance and herniation volume demonstrated no difference in both groups. There was no statistically significant difference in rates of postoperative intracranial infection, hematoma progression, secondary operation, hydrocephalus, subdural hygroma and seizure in both groups. KPS score in absorbable dura group (37.95 ± 28.58) was statistically higher than nonabsorbable dura group (49.05 ± 24.85) in one year after operation (P = 0.040), while no difference was found in the rate of functional independence (KPS ≥ 70). Besides, among all patients in this study, TCH patients had a higher mortality rate (P = 0.008), lower KPS scores (P < 0.001) and lower functionally independent rate (P = 0.049) in one year after surgery than patients without TCH. Conclusions In terms of artificial biological dura, nonabsorbable dura is superior to absorbable dura in treatment of severe TBI patients with DC. Suturable nonabsorbable dura has fewer complications of TCH and CFS leakage, and manifest lower mortality and better prognosis. Postoperative TCH is an important complication in severe TBI which usually leads to a poor prognosis.
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Affiliation(s)
- Zhong-Ding Zhang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Li-Yan Zhao
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yi-Ru Liu
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Jing-Yu Zhang
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Shang-Hui Xie
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yan-Qi Lin
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Zhuo-Ning Tang
- West China School of Public Health, Sichuan University, Chengdu, China
| | - Huang-Yi Fang
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yue Yang
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Shi-Ze Li
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Jian-Xi Liu
- Department of Neurosurgery, Yueqing Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Han-Song Sheng
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
- Correspondence: Han-Song Sheng
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Jha RM, Raikwar SP, Mihaljevic S, Casabella AM, Catapano JS, Rani A, Desai S, Gerzanich V, Simard JM. Emerging therapeutic targets for cerebral edema. Expert Opin Ther Targets 2021; 25:917-938. [PMID: 34844502 PMCID: PMC9196113 DOI: 10.1080/14728222.2021.2010045] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/20/2021] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Cerebral edema is a key contributor to death and disability in several forms of brain injury. Current treatment options are limited, reactive, and associated with significant morbidity. Targeted therapies are emerging based on a growing understanding of the molecular underpinnings of cerebral edema. AREAS COVERED We review the pathophysiology and relationships between different cerebral edema subtypes to provide a foundation for emerging therapies. Mechanisms for promising molecular targets are discussed, with an emphasis on those advancing in clinical trials, including ion and water channels (AQP4, SUR1-TRPM4) and other proteins/lipids involved in edema signaling pathways (AVP, COX2, VEGF, and S1P). Research on novel treatment modalities for cerebral edema [including recombinant proteins and gene therapies] is presented and finally, insights on reducing secondary injury and improving clinical outcome are offered. EXPERT OPINION Targeted molecular strategies to minimize or prevent cerebral edema are promising. Inhibition of SUR1-TRPM4 (glyburide/glibenclamide) and VEGF (bevacizumab) are currently closest to translation based on advances in clinical trials. However, the latter, tested in glioblastoma multiforme, has not demonstrated survival benefit. Research on recombinant proteins and gene therapies for cerebral edema is in its infancy, but early results are encouraging. These newer modalities may facilitate our understanding of the pathobiology underlying cerebral edema.
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Affiliation(s)
- Ruchira M. Jha
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Department of Neurobiology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Sudhanshu P. Raikwar
- Department of Neurobiology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Sandra Mihaljevic
- Department of Neurobiology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | | | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Anupama Rani
- Department of Neurobiology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Shashvat Desai
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore MD, USA
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore MD, USA
- Department of Pathology, University of Maryland School of Medicine, Baltimore MD, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore MD, USA
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Lazaridis C. Deciding Under Uncertainty: The Case of Refractory Intracranial Hypertension. Front Neurol 2020; 11:908. [PMID: 32973664 PMCID: PMC7468512 DOI: 10.3389/fneur.2020.00908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/14/2020] [Indexed: 02/05/2023] Open
Abstract
A challenging clinical conundrum arises in severe traumatic brain injury patients who develop intractable intracranial hypertension. For these patients, high morbidity interventions such as surgical decompression and barbiturate coma have to be considered against a backdrop of uncertain outcomes including prolonged states of disordered consciousness and severe disability. The clinical evidence available to guide shared decision-making is mainly limited to one randomized controlled trial, the RESCUEicp. However, since the publication of this trial significant controversy has been ongoing over the interpretation of the results. Is the mortality benefit from surgery merely a trade off for unacceptable long-term disability? How should treatment options, possible outcomes, and results from the trial be communicated to surrogates? How do we incorporate patient values into forming plans of care? The aim of this article is to sketch an approach based on insights from Decision Theory, and specifically deciding under uncertainty. The mainstream normative decision theory, Expected Utility (EU) theory, essentially says that, in situations of uncertainty, one should prefer the option with greatest expected desirability or value. The steps required to compute expected utilities include listing the possible outcomes of available interventions, assigning each outcome a utility ranking representing an individual patient's preferences, and a conditional probability given each intervention. This is a conceptual framework meant to supplement, and enhance shared decision making by assuring that patient values are elicited and incorporated, the possible range and nature of outcomes is discussed, and finally by attempting to connect best available means to patient-individualized ends.
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Affiliation(s)
- Christos Lazaridis
- Neurocritical Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, IL, United States.,Section of Neurosurgery, Department of Surgery, University of Chicago Medical Center, Chicago, IL, United States
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5
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Zhao T, Wang Z, Zhu T, Xie R, Zhu J. Downregulation of Thbs4 caused by neurogenic niche changes promotes neuronal regeneration after traumatic brain injury. Neurol Res 2020; 42:703-711. [PMID: 32684116 DOI: 10.1080/01616412.2020.1795590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Following brain injury, the neurogenic niche provides a permissive cue for iatrogenesis rather than neurogenesis; reactive astrocytes play essential roles in orchestrating this process, markedly forming a glial scar around the area of damaged brain tissue. The objective of this study was to alter the neurogenic niche at the injured cortex and study its impact on neurogenesis. METHODS We constructed a stromal cell-derived factor 1 (SDF-1) gradient matrix to attract reactive astrocytes to the glial scar core. RESULTS SDF-1 reacted with the astrocytes in the injured site. By changing the neurogenic niche of the injured part of the brain after traumatic brain injury (TBI), SDF-1 downregulated thrombospondin 4 (Thbs4) promoting neuronal cell regeneration and playing a beneficial role in nerve function recovery after brain injury. DISCUSSION The matrix we created in this study could attract and interact with reactive glial cells and, thus, we called it a glial pump. Using the glial pump, we identified a new mechanism of brain injury repair and neuronal regeneration after TBI, which relied on Thbs4 downregulation after the altered neurogenic niche promoted neuronal regeneration and functional recovery.
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Affiliation(s)
- Tong Zhao
- Department of Neurosurgery, Fudan University Huashan Hospital , Shanghai, China.,State Key Laboratory of Medical Neurobiology, The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Shanghai Medical College, Fudan University , Shanghai, China
| | - Zhifu Wang
- Department of Neurosurgery, Fudan University Huashan Hospital , Shanghai, China.,State Key Laboratory of Medical Neurobiology, The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Shanghai Medical College, Fudan University , Shanghai, China
| | - Tongming Zhu
- Department of Neurosurgery, Fudan University Huashan Hospital , Shanghai, China.,State Key Laboratory of Medical Neurobiology, The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Shanghai Medical College, Fudan University , Shanghai, China
| | - Rong Xie
- Department of Neurosurgery, Fudan University Huashan Hospital , Shanghai, China.,State Key Laboratory of Medical Neurobiology, The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Shanghai Medical College, Fudan University , Shanghai, China
| | - Jianhong Zhu
- Department of Neurosurgery, Fudan University Huashan Hospital , Shanghai, China.,State Key Laboratory of Medical Neurobiology, The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Shanghai Medical College, Fudan University , Shanghai, China
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Jha RM, Bell J, Citerio G, Hemphill JC, Kimberly WT, Narayan RK, Sahuquillo J, Sheth KN, Simard JM. Role of Sulfonylurea Receptor 1 and Glibenclamide in Traumatic Brain Injury: A Review of the Evidence. Int J Mol Sci 2020; 21:E409. [PMID: 31936452 PMCID: PMC7013742 DOI: 10.3390/ijms21020409] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 12/28/2019] [Accepted: 01/03/2020] [Indexed: 02/07/2023] Open
Abstract
Cerebral edema and contusion expansion are major determinants of morbidity and mortality after TBI. Current treatment options are reactive, suboptimal and associated with significant side effects. First discovered in models of focal cerebral ischemia, there is increasing evidence that the sulfonylurea receptor 1 (SUR1)-Transient receptor potential melastatin 4 (TRPM4) channel plays a key role in these critical secondary injury processes after TBI. Targeted SUR1-TRPM4 channel inhibition with glibenclamide has been shown to reduce edema and progression of hemorrhage, particularly in preclinical models of contusional TBI. Results from small clinical trials evaluating glibenclamide in TBI have been encouraging. A Phase-2 study evaluating the safety and efficacy of intravenous glibenclamide (BIIB093) in brain contusion is actively enrolling subjects. In this comprehensive narrative review, we summarize the molecular basis of SUR1-TRPM4 related pathology and discuss TBI-specific expression patterns, biomarker potential, genetic variation, preclinical experiments, and clinical studies evaluating the utility of treatment with glibenclamide in this disease.
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Affiliation(s)
- Ruchira M. Jha
- Departments of Critical Care Medicine, Neurology, Neurological Surgery, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15201, USA
| | | | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, 20121 Milan, Italy;
- Anaesthesia and Intensive Care, San Gerardo and Desio Hospitals, ASST-Monza, 20900 Monza, Italy
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA 94110, USA;
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA 02108, USA;
| | - Raj K. Narayan
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, USA;
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d′Hebron Research Institute (VHIR), 08001 Barcelona, Spain;
- Department of Neurosurgery, Universitat Autònoma de Barcelona (UAB), 08001 Barcelona, Spain
- Department of Neurosurgery, Vall d′Hebron University Hospital, 08001 Barcelona, Spain
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT 06501, USA;
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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7
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Decompressive Craniectomy for Patients with Traumatic Brain Injury: A Pooled Analysis of Randomized Controlled Trials. World Neurosurg 2020; 133:e135-e148. [DOI: 10.1016/j.wneu.2019.08.184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/21/2022]
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8
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Changa AR, Czeisler BM, Lord AS. Management of Elevated Intracranial Pressure: a Review. Curr Neurol Neurosci Rep 2019; 19:99. [DOI: 10.1007/s11910-019-1010-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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9
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Rubiano AM, Carney N, Khan AA, Ammirati M. The Role of Decompressive Craniectomy in the Context of Severe Traumatic Brain Injury: Summary of Results and Analysis of the Confidence Level of Conclusions From Systematic Reviews and Meta-Analyses. Front Neurol 2019; 10:1063. [PMID: 31649610 PMCID: PMC6795698 DOI: 10.3389/fneur.2019.01063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/20/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction: Traumatic brain injury (TBI) is a global epidemic. The incidence of TBI in low and middle-income countries (LMICs) is three times greater than in high-income countries (HICs). Decompressive craniectomy (DC) is a surgical procedure to reduce intracranial pressure (ICP) and prevent secondary injury. Multiple comparative studies, and several randomized controlled trials (RCTs) have been conducted to investigate the influence of DC for patients with severe TBI on outcomes such as mortality, ICP, neurological outcomes, and intensive care unit (ICU) and hospital length of stay. The results of these studies are inconsistent. Systematic reviews and meta-analyses have been conducted in an effort to aggregate the data from the individual studies, and perhaps derive reliable conclusions. The purpose of this project was to conduct a review of the reviews about the effectiveness of DC to improve outcomes. Methods: We conducted a systematic search of the literature to identify reviews and meta-analyses that met our pre-determined criteria. We used the AMSTAR 2 instrument to assess the quality of each of the included reviews, and determine the level of confidence. Results: Of 973 citations from the original search, five publications were included in our review. Four of them included meta-analyses. For mortality, three reviews found a positive effect of DC compared to medical management and two found no significant difference between groups. The four reviews that measured neurological outcome found no benefit of DC. The two reviews that assessed ICP both found DC to be beneficial in reducing ICP. DC demonstrated a significant reduction in ICU length of stay in the one study that measured it, and a significant reduction in hospital length of stay in the two studies that measured it. According to the AMSTAR 2 criteria, the five reviews ranged in levels of confidence from low to critically low. Conclusion: Systematic reviews and meta-analyses are important approaches for aggregating information from multiple studies. Clinicians rely of these methods for concise interpretation of scientific literature. Standards for quality of systematic reviews and meta-analyses have been established to support the quality of the reviews being produced. In the case of DC, more attention must be paid to quality standards, in the generation of both individual studies and reviews.
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Affiliation(s)
- Andrés M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogota, Colombia.,NIHR Global Health Research Group on Neurotrauma, MEDITECH Foundation, Cali, Colombia
| | - Nancy Carney
- School of Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Ahsan A Khan
- NIHR Global Health Research Group on Neurotrauma, MEDITECH Foundation, Cali, Colombia
| | - Mario Ammirati
- Center for Biotechnology, Department of Biology, College of Science and Technology, Temple University, Philadelphia, PA, United States.,Innovative Neurotherapeutic Research Program Sbarro Health Organization, Temple University, Philadelphia, PA, United States
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Citerio G, Prisco L, Oddo M, Meyfroidt G, Helbok R, Stocchetti N, Taccone F, Vincent JL, Robba C, Elli F, Sala E, Vargiolu A, Lingsma H. International prospective observational study on intracranial pressure in intensive care (ICU): the SYNAPSE-ICU study protocol. BMJ Open 2019; 9:e026552. [PMID: 31005932 PMCID: PMC6500252 DOI: 10.1136/bmjopen-2018-026552] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Intracranial pressure (ICP) monitoring is commonly used in neurocritical care patients with acute brain injury (ABI). Practice about indications and use of ICP monitoring in patients with ABI remains, however, highly variable in high-income countries, while data on ICP monitoring in low and middle-income countries are scarce or inconsistent. The aim of the SYNAPSE-ICU study is to describe current practices of ICP monitoring using a worldwide sample and to quantify practice variations in ICP monitoring and management in neurocritical care ABI patients. METHODS AND ANALYSIS The SYNAPSE-ICU study is a large international, prospective, observational cohort study. From March 2018 to March 2019, all patients fulfilling the following inclusion criteria will be recruited: age >18 years; diagnosis of ABI due to primary haemorrhagic stroke (subarachnoid haemorrhage or intracranial haemorrhage) or traumatic brain injury; Glasgow Coma Score (GCS) with no eye opening (Eyes response=1) and Motor score ≤5 (not following commands) at ICU admission, or neuro-worsening within the first 48 hours with no eye opening and a Motor score decreased to ≤5. Data related to clinical examination (GCS, pupil size and reactivity, Richmond Agitation-Sedation Scale score, neuroimaging) and to ICP interventions (Therapy Intensity Levels) will be recorded on admission, and at day 1, 3 and 7. The Glasgow Outcome Scale Extended (GOSE) will be collected at discharge from ICU and from hospital and at 6-month follow-up. The impact of ICP monitoring and ICP-driven therapy on GOSE will be analysed at both patient and ICU level. ETHICS AND DISSEMINATION The study has been approved by the Ethics Committee 'Brianza' at the Azienda Socio Sanitaria Territoriale (ASST)-Monza (approval date: 21 November 2017). Each National Coordinator will notify the relevant ethics committee, in compliance with the local legislation and rules. Data will be made available to the scientific community by means of abstracts submitted to the European Society of Intensive Care Medicine annual conference and by scientific reports and original articles submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03257904.
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Affiliation(s)
- Giuseppe Citerio
- Scuola di Medicina e Chirurgia, Università Milano Bicocca, Monza, Italy
| | - Lara Prisco
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Mauro Oddo
- Department of Intensive Care Medicine, CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals, Leuven, Belgium
| | - Raimund Helbok
- Department of Neurology, Neurocritical Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Nino Stocchetti
- Department of Physiopathology and Transplant, Università degli Studi di Milano, Milano, Italy
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Fabio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
- Anesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova
| | - Francesca Elli
- Scuola di Medicina e Chirurgia, Università Milano Bicocca, Monza, Italy
| | - Elisa Sala
- Scuola di Medicina e Chirurgia, Università Milano Bicocca, Monza, Italy
| | - Alessia Vargiolu
- Scuola di Medicina e Chirurgia, Università Milano Bicocca, Monza, Italy
| | - Hester Lingsma
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands
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11
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Zhou JK, Zhang QS, Chen YQ, Li M, Xie Y, Ke JJ, Lin HZ, Zhang YW. Use of Hematocrit for Short-Term Prognosis of Patients with Traumatic Brain Injury After Decompressive Craniectomy. World Neurosurg 2019; 123:e141-e146. [PMID: 30468923 DOI: 10.1016/j.wneu.2018.11.095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To discuss the effects of the hematocrit (Hct) in patients with traumatic brain injury after decompressive craniectomy (DC). METHODS Demographic data, inspection and treatment procedures, and 30-day prognosis were obtained for 158 patients with head injury who underwent unilateral DC in our hospital between January 2013 and June 2018. Uni- and multivariate logistic regression was applied to analyze independent risk factors for 30-day outcome. The quantitative analysis of postoperative Hct, ΔHct (postoperative Hct minus initial Hct), and their combination for the prognosis of patients with TBI was displayed graphically using receiver operating characteristic (ROC) curves. Multiple linear regression was used to explore factors influencing postoperative Hct and ΔHct. RESULTS Short-term mortality was 29.7%. Uni- and multivariate logistic regression analysis showed that age (odds ratio [OR], 1.064; P = 0.024), Glasgow Coma Scale score (OR, 0.711; P = 0.027), Injury Severity Score (ISS) (OR, 1.156; P = 0.047), midline shift in millimeters (OR, 1.809; P <0.001), postoperative Hct (OR, 0.743; P = 0.001), and ΔHct (OR, 1.242; P =0.048) were independent risk factors for short-term death. In ROC curves, a combination of postoperative Hct and ΔHct showed the highest sensitivity (77.5%) and highest specificity (89.4%). When using this combination to predict prognosis, we could achieve an accuracy of 94.5%. ISS (β = -0.172, P = 0.022), initial Hct (β = 0.243, P = 0.001), principal hematoma location (β = -2.628, P < 0.001), hours of operation (β = -0.884, P = 0.048), and colloid quantity (β = -0.002, P = 0.001) were independent contributing factors for ΔHct, which was similar to postoperative Hct. CONCLUSIONS A combination of postoperative Hct and ΔHct could better predict short-term survival of patients with TBI. Developing an appropriate treatment strategy to increase postoperative Hct and reduce the ΔHct may be good for the short-term prognosis of patients with TBI after DC.
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Affiliation(s)
- Jin-Kui Zhou
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Qi-Shuo Zhang
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Yu-Qiang Chen
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Mu Li
- Department of Neurosurgery, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Yang Xie
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China.
| | - Jia-Jie Ke
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Huan-Zhang Lin
- Thyroid Surgery, Shantou Central Hospital Affiliated Shantou Hospital of Sun Yat-sen University, Shantou, Guangdong Province, China
| | - Yao-Wei Zhang
- Department of Emergency, Shantou University Medical College, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
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Tian R, Liu W, Dong J, Zhang J, Xu L, Zhang B, Tao X, Li J, Liu B. Prognostic Predictors of Early Outcomes and Discharge Status of Patients Undergoing Decompressive Craniectomy After Severe Traumatic Brain Injury. World Neurosurg 2019; 126:e101-e108. [PMID: 30790726 DOI: 10.1016/j.wneu.2019.01.246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Although several prognostic factors for traumatic brain injury (TBI) have been evaluated, a useful predictive scoring model for the outcomes has not been developed for patients with severe TBI who undergo decompressive craniectomy (DC). The aim of the present study was to determine independent predictors and develop a multivariate logistic regression equation to predict the early outcome and discharge status for patients with severe TBI who have undergone DC. METHODS A total of 13 different variables were evaluated. The data from all 278 patients with severe TBI who had undergone DC in the present study were retrospectively evaluated from July 2011 to June 2017. Using univariate, multiple logistic regression and prognostic regression scoring equations it was possible to draw receiver operating characteristic curves to predict the early outcomes and discharge status after TBI. RESULTS We found that younger age (P = 0.012), no significant medical history (P = 0.044), diameter of both pupils <4 mm (P = 0.032), higher admission Glasgow coma scale score (P = 0.004), no tracheotomy (P < 0.001), and DC for severe TBI were associated with a favorable early outcome and discharge status. Using receiver operating characteristic curves to predict the probability of a favorable outcome, the sensitivity was 80.0% and the specificity was 79.5%. CONCLUSIONS Our preliminary findings have shown that 5 variables can be used as independent predictors in assessing the early outcome and discharge status for patients with severe TBI after DC.
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Affiliation(s)
- Runfa Tian
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Jinqian Dong
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Ji Zhang
- Department of Neurosurgery, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Long Xu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Bin Zhang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Xiaogang Tao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Jingsheng Li
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Beijing, People's Republic of China.
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14
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Tsaousi GG, Marocchi L, Sergi PG, Pourzitaki C, Santoro A, Bilotta F. Early and late clinical outcomes after decompressive craniectomy for traumatic refractory intracranial hypertension: a systematic review and meta-analysis of current evidence. J Neurosurg Sci 2018; 64:97-106. [PMID: 30356035 DOI: 10.23736/s0390-5616.18.04527-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Decompressive craniectomy (DC) to control refractory intracranial hypertension in patients with traumatic brain injury (TBI), has been listed as possible but controversial therapeutic approach in the latest version of TBI management guidelines. This study aimed to perform a systematic review and meta-analysis on efficacy and safety of DC compared to standard care in TBI patients. EVIDENCE ACQUISITION A database search from 2011 to 2017 was conducted to identify studies pertinent to DC compared to standard care after TBI. The primary outcomes were mortality and functional outcome upon hospital discharge and at 6 and 12 months after intervention, whereas secondary outcomes were intracranial pressure (ICP) control, hospitalization data and occurrence of adverse events. EVIDENCE SYNTHESIS Three randomized controlled trials and two observational studies enrolling 3451 patients were selected for qualitative analysis, among which four were included in the meta-analysis. DC-treated patients showed a significant reduction of overall mortality (RR, 0.57; 95% CI: 0.5-0.66; P<0.001; I2=17%) with no profound beneficial effect on functional outcome (RR, 0.89; 95% CI: 0.78-1.02; P=0.09; I2=58%) compared to those receiving standard care. A more efficient ICP reduction and a tendency towards shorter duration of hospitalization were recorded in DC versus standard care group. Adverse events are more common in DC-treated patients. CONCLUSIONS It seems that, in TBI patients with intracranial hypertension, the use of DC is associated with survival benefit when compared to medical therapy alone, but with no clear improvement of functional outcome. Yet no definite conclusion can be drawn due to limited quantity and considerable heterogeneity of available data.
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Affiliation(s)
- Georgia G Tsaousi
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece -
| | - Lorenzo Marocchi
- Department of Anesthesiology and Intensive Care Medicine, Sapienza University, Rome, Italy
| | - Paola G Sergi
- Department of Anesthesiology and Intensive Care Medicine, Sapienza University, Rome, Italy
| | - Chryssa Pourzitaki
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonio Santoro
- Department of Neurosurgery, Sapienza University, Rome, Italy
| | - Federico Bilotta
- Department of Anesthesiology and Intensive Care Medicine, Sapienza University, Rome, Italy
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15
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Abstract
The care of patients with traumatic brain injury can be one of the most challenging and rewarding aspects of clinical neurocritical care. This article reviews the approach to unique aspects specific to the care of this patient population. These aspects include appropriate use of sedation and analgesia, and the principles and the clinical use of intracranial monitors. Common clinical challenges encountered in these patients are also discussed, including the treatment of intracranial hypertension, temperature management, and control of sympathetic hyperactivity.
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16
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Dong HJ, Zhao ML, Li XH, Chen YS, Wang J, Chen MB, Wu S, Wang JJ, Liang HQ, Sun HT, Tu Y, Zhang S, Xiong J, Chen C. Hypothermia-Modulating Matrix Elasticity of Injured Brain Promoted Neural Lineage Specification of Mesenchymal Stem Cells. Neuroscience 2018; 377:1-11. [DOI: 10.1016/j.neuroscience.2018.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 02/06/2018] [Accepted: 02/08/2018] [Indexed: 12/15/2022]
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17
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Moskowitz J, Quinn T, Khan MW, Shutter L, Goldberg R, Col N, Mazor KM, Muehlschlegel S. Should We Use the IMPACT-Model for the Outcome Prognostication of TBI Patients? A Qualitative Study Assessing Physicians' Perceptions. MDM Policy Pract 2018; 3:2381468318757987. [PMID: 30288437 PMCID: PMC6124938 DOI: 10.1177/2381468318757987] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 12/26/2017] [Indexed: 11/15/2022] Open
Abstract
Introduction. Shared Decision-Making may facilitate information exchange, deliberation, and effective decision-making, but no decision aids currently exist for difficult decisions in neurocritical care patients. The International Patient Decision Aid Standards, a framework for the creation of high-quality decision aids (DA), recommends the presentation of numeric outcome and risk estimates. Efforts are underway to create a goals-of-care DA in critically-ill traumatic brain injury (ciTBI) patients. To inform its content, we examined physicians’ perceptions, and use of the IMPACT-model, the most widely validated ciTBI outcome model, and explored physicians’ preferences for communicating prognostic information towards families. Methods. We conducted a qualitative study using semi-structured interviews in 20 attending physicians (neurosurgery,neurocritical care,trauma,palliative care) at 7 U.S. academic medical centers. We used performed qualitative content analysis of transcribed interviews to identify major themes. Results. Only 12 physicians (60%) expressed awareness of the IMPACT-model; two stated that they “barely” knew the model. Seven physicians indicated using the model at least some of the time in clinical practice, although none used it exclusively to derive a patient’s prognosis. Four major themes emerged: the IMPACT-model is intended for research but should not be applied to individual patients; mistrust in the IMPACT-model derivation data; the IMPACT-model is helpful in reducing prognostic variability among physicians; concern that statistical models may mislead families about a patient’s prognosis. Discussion: Our study identified significant variability of the awareness, perception, and use of the IMPACT-model among physicians. While many physicians prefer to avoid conveying numeric prognostic estimates with families using the IMPACT-model, several physicians thought that they “ground” them and reduce prognostic variability among physicians. These findings may factor into the creation and implementation of future ciTBI-related DAs.
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Affiliation(s)
- Jesse Moskowitz
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Thomas Quinn
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Muhammad W Khan
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Lori Shutter
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Robert Goldberg
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Nananda Col
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Kathleen M Mazor
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
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18
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Definition of Traumatic Brain Injury, Neurosurgery, Trauma Orthopedics, Neuroimaging, Psychology, and Psychiatry in Mild Traumatic Brain Injury. Neuroimaging Clin N Am 2018; 28:1-13. [DOI: 10.1016/j.nic.2017.09.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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19
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Marehbian J, Muehlschlegel S, Edlow BL, Hinson HE, Hwang DY. Medical Management of the Severe Traumatic Brain Injury Patient. Neurocrit Care 2017; 27:430-446. [PMID: 28573388 PMCID: PMC5700862 DOI: 10.1007/s12028-017-0408-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Severe traumatic brain injury (sTBI) is a major contributor to long-term disability and a leading cause of death worldwide. Medical management of the sTBI patient, beginning with prehospital triage, is aimed at preventing secondary brain injury. This review discusses prehospital and emergency department management of sTBI, as well as aspects of TBI management in the intensive care unit where advances have been made in the past decade. Areas of emphasis include intracranial pressure management, neuromonitoring, management of paroxysmal sympathetic hyperactivity, neuroprotective strategies, prognostication, and communication with families about goals of care. Where appropriate, differences between the third and fourth editions of the Brain Trauma Foundation guidelines for the management of severe traumatic brain injury are highlighted.
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Affiliation(s)
- Jonathan Marehbian
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesia/Critical Care, and Surgery, University of Massachusetts Medical School, 55 Lake Ave North, S-5, Worcester, MA, 01655, USA
| | - Brian L Edlow
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, 55 Fruit Street - Lunder 650, Boston, MA, 02114, USA
| | - Holly E Hinson
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, CR-127, Portland, OR, 97239, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520, USA.
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20
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Abstract
The care of patients with traumatic brain injury can be one of the most challenging and rewarding aspects of clinical neurocritical care. This article reviews the approach to unique aspects specific to the care of this patient population. These aspects include appropriate use of sedation and analgesia, and the principles and the clinical use of intracranial monitors. Common clinical challenges encountered in these patients are also discussed, including the treatment of intracranial hypertension, temperature management, and control of sympathetic hyperactivity.
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Affiliation(s)
- Mohamed H Abou El Fadl
- Neurocritical Care, Department of Neurology, University of Miami, Miller School of Medicine, 1120 Northwest 14th Street, Suite 1356, Miami, FL 33136, USA
| | - Kristine H O'Phelan
- Neurocritical Care, Department of Neurology, University of Miami, Miller School of Medicine, 1120 Northwest 14th Street, Suite 1356, Miami, FL 33136, USA.
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21
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Khan AD, Elseth AJ, Head B, Rostas J, Dunn JA, Schroeppel TJ, Gonzalez RP. Indicators of Survival and Favorable Functional Outcomes after Decompressive Craniectomy: A Multi-Institutional Retrospective Study. Am Surg 2017. [DOI: 10.1177/000313481708300832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The role of decompressive craniectomy (DC) for severe traumatic brain injury (STBI) remains controversial. The purpose of this study was to identify factors that are indicators of survival and improved functional outcome in patients who undergo DC for STBI. A retrospective review of STBI patients who underwent DC was performed at four trauma centers during a 45-month period. Data collected included age, gender, mechanism of injury, Injury Severity Score (ISS), admission Glasgow Coma Scale (GCS), time from admission to DC, mortality, and extended Glasgow Outcome Score before discharge. Sixty-nine STBI patients were treated with DC during the study period. A higher initial GCS, lower ISS, and longer time to DC were all statistically significant for improved survival after DC. A younger age, higher initial GCS, and lower ISS were all statistically significant for a favorable functional outcome after DC. Patients with a higher initial GCS and lower ISS are more likely to survive DC and have a favorable functional outcome, whereas a longer time to DC was indicative of improved survival after DC.
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Affiliation(s)
- Abid D. Khan
- Department of Trauma and Acute Care Surgery, University of Colorado Health-Memorial Hospital, Colorado Springs, Colorado
| | - Anna J. Elseth
- Department of Trauma and Acute Care Surgery, University of Colorado Health-Memorial Hospital, Colorado Springs, Colorado
| | - Brian Head
- Division of Trauma, Burn, Surgical Critical Care and Acute Care Surgery, Department of Surgery, University of South Alabama, Mobile, Alabama
| | - Jack Rostas
- Division of Trauma, Burn, Surgical Critical Care and Acute Care Surgery, Department of Surgery, University of South Alabama, Mobile, Alabama
| | - Julie A. Dunn
- Department of Trauma and Acute Care Surgery, Medical Center of the Rockies, Fort Collins, Colorado
| | - Thomas J. Schroeppel
- Department of Trauma and Acute Care Surgery, University of Colorado Health-Memorial Hospital, Colorado Springs, Colorado
| | - Richard P. Gonzalez
- Department of Surgery, Division of Trauma and Acute Care Surgery, Loyola University Medical Center, Maywood, Illinois
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22
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Tapper J, Skrifvars MB, Kivisaari R, Siironen J, Raj R. Primary decompressive craniectomy is associated with worse neurological outcome in patients with traumatic brain injury requiring acute surgery. Surg Neurol Int 2017; 8:141. [PMID: 28781918 PMCID: PMC5523471 DOI: 10.4103/sni.sni_453_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/06/2017] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The role of decompressive craniectomy in treating raised intracranial pressure (ICP) after traumatic brain injuries (TBI) is controversial. The aim of this study was to assess the differences in prognosis of patients initially treated by decompressive craniectomy, craniotomy, or conservatively. METHODS We conducted a single-center retrospective study on adult blunt TBI patients admitted to a neurosurgical intensive care unit during 2009-2012. Patients were divided into three groups based on their initial treatment - decompressive craniectomy, craniotomy, and conservative. Primary outcome was 6-month Glasgow Outcome Scale (GOS) dichotomized to favorable outcome (independent) and unfavorable outcome (dependent). The association between initial treatment and outcome was assessed using a logistic regression model adjusting for case-mix using known predictors of outcome. RESULTS Of the 822 included patients, 58 patients were in the craniectomy group, 401 patients in the craniotomy group, and 363 patients in the conservatively treated group. Overall, 6-month unfavorable outcome was 48%. After adjusting for case-mix, patients in the decompressive craniectomy group had a statistical significantly higher risk for poor neurological outcome compared to patients in the conservative group (OR 3.06, 95% CI 1.45-6.42) and craniotomy group (OR 3.61, 95% CI 1.74-7.51). CONCLUSION In conclusion, patients requiring primary decompressive craniectomy had a higher risk for poor neurological outcome compared to patients undergoing craniotomy or were conservatively treated. It is plausible that the poor prognosis is related to the TBI severity itself rather than the intervention. Further prospective randomized trials are required to establish the role of decompressive craniectomy in the treatment of patients with TBI.
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Affiliation(s)
- Julius Tapper
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Markus B. Skrifvars
- Department of Anesthesiology, Intensive Care and Pain Medicine, Division of Intensive Care, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Australian and New Zealand Intensive Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Riku Kivisaari
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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23
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Trial of decompressive craniectomy for traumatic intracranial hypertension. J Intensive Care Soc 2017; 18:236-238. [PMID: 29118837 DOI: 10.1177/1751143716685246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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