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Zhang Y, Zheng Z, Sun J, Xu S, Wei Y, Ding X, Ding G. The application of mesenchymal stem cells in the treatment of traumatic brain injury: Mechanisms, results, and problems. Histol Histopathol 2024; 39:1109-1131. [PMID: 38353136 DOI: 10.14670/hh-18-716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
Mesenchymal stem cells (MSCs) are multipotent stromal cells that can be derived from a wide variety of human tissues and organs. They can differentiate into a variety of cell types, including osteoblasts, adipocytes, and chondrocytes, and thus show great potential in regenerative medicine. Traumatic brain injury (TBI) is an organic injury to brain tissue with a high rate of disability and death caused by an external impact or concussive force acting directly or indirectly on the head. The current treatment of TBI mainly includes symptomatic, pharmacological, and rehabilitation treatment. Although some efficacy has been achieved, the definitive recovery effect on neural tissue is still limited. Recent studies have shown that MSC therapies are more effective than traditional treatment strategies due to their strong multi-directional differentiation potential, self-renewal capacity, and low immunogenicity and homing properties, thus MSCs are considered to play an important role and are an ideal cell for the treatment of injurious diseases, including TBI. In this paper, we systematically reviewed the role and mechanisms of MSCs and MSC-derived exosomes in the treatment of TBI, thereby providing new insights into the clinical applications of MSCs and MSC-derived exosomes in the treatment of central nervous system disorders.
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Affiliation(s)
- Ying Zhang
- School of Stomatology, Shandong Second Medical University, Weifang, Shandong Province, China
| | - Zejun Zheng
- School of Stomatology, Shandong Second Medical University, Weifang, Shandong Province, China
| | - Jinmeng Sun
- School of Stomatology, Shandong Second Medical University, Weifang, Shandong Province, China
| | - Shuangshuang Xu
- School of Stomatology, Shandong Second Medical University, Weifang, Shandong Province, China
| | - Yanan Wei
- School of Stomatology, Shandong Second Medical University, Weifang, Shandong Province, China
| | - Xiaoling Ding
- Clinical Competency Training Center, Shandong Second Medical University, Weifang, Shandong Province, China.
| | - Gang Ding
- School of Stomatology, Shandong Second Medical University, Weifang, Shandong Province, China.
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White AJ, Kelly-Hedrick M, Miranda SP, Abdelbarr MM, Lázaro-Muñoz G, Pouratian N, Shen F, Nahed BV, Williamson T. Bioethics and Neurosurgery: An Overview of Existing and Emerging Topics for the Practicing Neurosurgeon. World Neurosurg 2024; 190:181-186. [PMID: 39004179 DOI: 10.1016/j.wneu.2024.07.051] [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: 06/05/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024]
Abstract
Neurosurgery is a field with complex ethical issues. In this article, we aim to provide an overview of key and emerging ethical issues in neurosurgery with a focus on issues relevant to practicing neurosurgeons. These issues include those of informed consent, capacity, clinical trials, emerging neurotechnology, innovation, equity and justice, and emerging bioethics areas including community engagement and organizational ethics. We argue that bioethics can help neurosurgeons think about and address these issues, and, in turn, the field of bioethics can benefit from engagement by neurosurgeons. Several ideas for increasing engagement in bioethics are proposed.
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Affiliation(s)
- Alexandra J White
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Margot Kelly-Hedrick
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
| | - Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Pennsylvania, Pennsylvania, USA
| | | | | | - Nader Pouratian
- Department of Neurological Surgery, University of Texas Southwestern, Dallas, Texas, USA
| | - Francis Shen
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA; Harvard Law School, Cambridge, Massachusetts, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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Bako AT, Potter T, Pan AP, Tannous J, Britz G, Ziai WC, Awad I, Hanley D, Vahidy FS. Minimally Invasive Surgery With Thrombolysis for Intracerebral Hemorrhage Evacuation: Bayesian Reanalysis of a Randomized Controlled Trial. Neurology 2023; 101:e1614-e1622. [PMID: 37684058 PMCID: PMC10585679 DOI: 10.1212/wnl.0000000000207735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 06/20/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Bayesian analysis of randomized controlled trials (RCTs) can extend the value of trial data beyond interpretations based on conventional p value-based binary cutoffs. We conducted an exploratory post hoc Bayesian reanalysis of the minimally invasive surgery with thrombolysis for intracerebral hemorrhage (ICH) evacuation (MISTIE-3) trial and derived probabilities of potential intervention effect on functional and survival outcomes. METHODS MISTIE-3 was a multicenter phase 3 RCT designed to evaluate the efficacy and safety of the MISTIE intervention. Five hundred and six adults (18 years or older) with spontaneous, nontraumatic, supratentorial ICH of ≥30 mL were randomized to receive either the MISTIE intervention (n = 255) or standard medical care (n = 251). We provide Bayesian-derived estimates of the effect of the MISTIE intervention on achieving a good 365-day modified Rankin Scale score (mRS score 0-3) as relative risk (RR) and absolute risk difference (ARD), and the probabilities that these treatment effects are greater than prespecified thresholds. We used 2 sets of prior distributions: (1) reference priors, including minimally informative, enthusiastic, and skeptical priors, and (2) data-derived prior distribution, using a hierarchical random effects model. We additionally evaluated the potential effects of the MISTIE intervention on 180-day and 30-day mRS and 365-, 180-, and 30-day mortality using data-derived priors. RESULTS The Bayesian-derived probability that MISTIE intervention has any beneficial effect (RR >1) on achieving a good 365-day mRS score was 70% using minimally informative prior, 87% with enthusiastic prior, 68% with skeptical prior, and 73% with data-derived prior. However, these probabilities were ≤55% for RR >1.10 and 0% for RR >1.52 across a range of priors. The probabilities of achieving RR >1 for 180- and 30-day mRS scores are 65% and 80%, respectively. Furthermore, the probabilities of achieving RR <1 for 365-, 180-, and 30-day mortality are 93%, 98%, and 99%, respectively. DISCUSSION Our exploratory analyses indicate that across a range of priors, the Bayesian-derived probability of MISTIE intervention having any beneficial effect on 365-day mRS for patients with ICH is between 68% and 87%. These analyses do not change the frequentist-based interpretation of the trial. However, unlike the frequentist p values, which indirectly evaluate treatment effects and only provide an arbitrary binary cutoff (such as 0.05), the Bayesian framework directly estimates the probabilities of potential treatment effects. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov/ct2/show/NCT01827046. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that minimally invasive surgery (MIS) + recombinant tissue plasminogen activator (rt-PA) does not significantly improve functional outcome in patients with ICH. However, this study lacks the precision to exclude a potential benefit of MIS + rt-PA.
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Affiliation(s)
- Abdulaziz T Bako
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Thomas Potter
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Alan P Pan
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Jonika Tannous
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Gavin Britz
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Wendy C Ziai
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Issam Awad
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Daniel Hanley
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL
| | - Farhaan S Vahidy
- From the Department of Neurosurgery (A.T.B., T.P., J.T., F.S.V.), and Center for Health Data Science and Analytics (A.P.P., G.B., F.S.V.), Houston Methodist, TX; Weill Cornell Medical College (G.B., F.S.V.), New York, NY; Houston Methodist Academic Institute (G.B., F.S.V.), TX; Division of Brain Injury Outcomes (W.C.Z., D.H.), Johns Hopkins University, Baltimore, MD; and Department of Neurological Surgery (I.A.), University of Chicago Medicine and Biological Sciences, IL.
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Wang J, Yin MJ, Wen HC. Prediction performance of the machine learning model in predicting mortality risk in patients with traumatic brain injuries: a systematic review and meta-analysis. BMC Med Inform Decis Mak 2023; 23:142. [PMID: 37507752 PMCID: PMC10385965 DOI: 10.1186/s12911-023-02247-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/25/2023] [Indexed: 07/30/2023] Open
Abstract
PURPOSE With the in-depth application of machine learning(ML) in clinical practice, it has been used to predict the mortality risk in patients with traumatic brain injuries(TBI). However, there are disputes over its predictive accuracy. Therefore, we implemented this systematic review and meta-analysis, to explore the predictive value of ML for TBI. METHODOLOGY We systematically retrieved literature published in PubMed, Embase.com, Cochrane, and Web of Science as of November 27, 2022. The prediction model risk of bias(ROB) assessment tool (PROBAST) was used to assess the ROB of models and the applicability of reviewed questions. The random-effects model was adopted for the meta-analysis of the C-index and accuracy of ML models, and a bivariate mixed-effects model for the meta-analysis of the sensitivity and specificity. RESULT A total of 47 papers were eligible, including 156 model, with 122 newly developed ML models and 34 clinically recommended mature tools. There were 98 ML models predicting the in-hospital mortality in patients with TBI; the pooled C-index, sensitivity, and specificity were 0.86 (95% CI: 0.84, 0.87), 0.79 (95% CI: 0.75, 0.82), and 0.89 (95% CI: 0.86, 0.92), respectively. There were 24 ML models predicting the out-of-hospital mortality; the pooled C-index, sensitivity, and specificity were 0.83 (95% CI: 0.81, 0.85), 0.74 (95% CI: 0.67, 0.81), and 0.75 (95% CI: 0.66, 0.82), respectively. According to multivariate analysis, GCS score, age, CT classification, pupil size/light reflex, glucose, and systolic blood pressure (SBP) exerted the greatest impact on the model performance. CONCLUSION According to the systematic review and meta-analysis, ML models are relatively accurate in predicting the mortality of TBI. A single model often outperforms traditional scoring tools, but the pooled accuracy of models is close to that of traditional scoring tools. The key factors related to model performance include the accepted clinical variables of TBI and the use of CT imaging.
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Affiliation(s)
- Jue Wang
- Department of Emergency, The First Affiliated Hospital of Guangxi Medical University, 530021, Nanning, Guangxi, China
| | - Ming Jing Yin
- Department of Emergency, The First Affiliated Hospital of Guangxi Medical University, 530021, Nanning, Guangxi, China
| | - Han Chun Wen
- Department of Emergency, The First Affiliated Hospital of Guangxi Medical University, 530021, Nanning, Guangxi, China.
- Intensive Care Department, Guangxi Medical University First Affiliated Hospital, Ward 1, No. 6 Shuangyong Road, Qingxiu District, Guangxi Zhuang Autonomous Region, Nanning, China.
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Mitchell T, Abdelgadir J, Oshotse C, Ubel PA, Williamson T. Definitely, Maybe: Helping Patients Make Decisions about Surgery When Prognosis Is Uncertain. THE JOURNAL OF CLINICAL ETHICS 2023; 34:169-174. [PMID: 37229741 DOI: 10.1086/724770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
AbstractThe sudden onset of severe traumatic brain injury (sTBI) is an event suffered by millions of individuals each year. Regardless of this frequency in occurrence, accurate prognostication remains difficult to achieve among physicians. There are many variables that affect this prognosis. Physicians are expected to assess the clinical indications of the brain injury while considering other factors such as patient quality of life, patient preferences, and environmental context. However, this lack of certainty in prognosis can ultimately affect treatment recommendations and prompt clinical ethical issues at the bedside, as it leaves room for physician bias and interpretation. In this article, we introduce data on neurosurgeon values that may shed light on the process physicians and patients involved in sTBI undergo. In doing so, we highlight the many nuances in decision-making for patients suffering from sTBI and discuss potential solutions to better patient-physician or surrogate-physician interactions.
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Shlobin NA, Garcia RM, Bernstein M. Neuropalliative care for the neurosurgeon: a primer. J Neurosurg 2022; 137:850-858. [PMID: 34920433 DOI: 10.3171/2021.9.jns211872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
Many neurosurgical conditions are incurable, leading to disability or severe symptoms, poor quality of life, and distress for patients and families. The field of neuropalliative care (NPC) addresses the palliative care (PC) needs of individuals living with neurological conditions. Neurosurgeons play an important role within multidisciplinary NPC teams because of their understanding of the natural history of and treatment strategies for neurosurgical conditions, longitudinal patient-physician relationships, and responsibility for neurosurgical emergencies. Moreover, patients with neurosurgical conditions have unique PC needs given the trajectories of neurosurgical diseases, the realities of prognostication, psychosocial factors, communication strategies, and human behavior. PC improves outcomes among neurosurgical patients. Despite the importance of NPC, neurosurgeons often lack formal training in PC skills, which include identifying patients who require PC, assessing a patient's understanding and preferences regarding illness, educating patients, building trust, managing symptoms, addressing family and caregiver needs, discussing end-of-life care, and recognizing when to refer patients to specialists. The future of NPC involves increasing awareness of the approach's importance, delineating priorities for neurosurgeons with regard to NPC, increasing emphasis on PC skills during training and practice, expanding research efforts, and adjusting reimbursement structures to incentivize the provision of NPC by neurosurgeons.
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Affiliation(s)
- Nathan A Shlobin
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Roxanna M Garcia
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark Bernstein
- 2Division of Neurosurgery, Toronto Western Hospital, University of Toronto; and
- 3Temmy Latner Center for Palliative Care, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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Morris RS, Figueroa JF, Pokrzywa CJ, Barber JK, Temkin NR, Bergner C, Karam BS, Murphy P, Nelson LD, Laud P, Cooper Z, de Moya M, Trevino C, Tignanelli CJ, deRoon-Cassini TA. Predicting outcomes after traumatic brain injury: A novel hospital prediction model for a patient reported outcome. Am J Surg 2022; 224:1150-1155. [DOI: 10.1016/j.amjsurg.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/14/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
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Superiority of craniotomy over supportive care for octogenarians and nonagenarians in operable acute traumatic subdural hematoma. Clin Neurol Neurosurg 2021; 212:107069. [PMID: 34844161 DOI: 10.1016/j.clineuro.2021.107069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Neurosurgical evacuation in elderly trauma patients is controversial. We analyzed impact of craniotomy for acute subdural hematoma on survival in octogenarians and nonagenarians. Methods The study population included all patients aged ≥ 80 years who presented with acute traumatic SDHs 09/01/15 - 01/01/20, with radiography indicating operative eligibility (i.e. MLS >5 mm and/or overall thickness >10 mm). Of 1054 TBIs aged ≥ 80 years, 104 (9.87%) were surgically indicated. Of these, 35 received craniotomy and 69 received supportive measures due to family/patient wishes or surgeon's professional decision. We analyzed these data using a Poisson regression adjusted for influence of covariates. RESULTS Of 35 craniotomies, 21 (60.00%) were deceased at 2 years of follow-up, compared to 48 (69.57%) deceased of 69 non-surgical patients. No significant demographic differences existed between these groups, other than age (craniotomy patients were younger; median age 84 vs 86; p < 0.001). In outcomes, the craniotomy cohort survived longer and in higher proportions (p = 0.028; Gehan-Breslow-Wilcoxon). When adjusting for covariates, this effect became more pronounced: craniotomy patients died at 41.1% the rate of non-surgical ones. Of all the covariates, only initial GCS significantly impacted the protective effect of craniotomy. In a logarithmic relationship, each point on initial GCS was associated with less benefit from surgery. We also found that patients with GCS< 3 were overall less likely to benefit from surgery. Our conclusions are limited by the impact of patient/surgeon choice on whether or not to operate. It is possible healthier subjects elected for craniotomies. We have attempted to correct for this by including comorbidities as covariates in our regression analyses. CONCLUSIONS Our results indicate a surgical benefit for this elderly cohort, consistent with prior findings of benefit in the setting of severe traumatic aSDH. Patients with worse neurologic impairment, i.e. low GCS, had the greatest survival benefit from surgical intervention.
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Azad TD. Opinion & Special Articles: Shared Decision-Making During the COVID-19 Pandemic: Three Bullets in 3 Hemispheres. Neurology 2021; 96:e2558-e2560. [PMID: 33692167 DOI: 10.1212/wnl.0000000000011811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients with traumatic brain injury may be dependent on the decision-making of their families. Restrictive visitation policies implemented during the coronavirus disease 2019 (COVID-19) pandemic disproportionately affect these patients and their families. This narrative aims to illustrate this phenomenon and catalyze discussions regarding the need for careful evaluation of restrictive family visitation policies and exceptions that may be required for patients with brain injuries.
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Affiliation(s)
- Tej D Azad
- From the Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD.
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