The Effect of Controlled Decompression for Severe Traumatic Brain Injury: A Randomized, Controlled Trial

The value of computed tomography angiography in predicting the surgical effect and prognosis of severe traumatic brain injury

It is difficult to predict the surgical effect and outcome of severe traumatic brain injury (TBI) before surgery. This study aims to approve an evaluation method of computed tomography angiography (CTA) to predict the effect of surgery and outcome in severe TBI. Between January 2010 and January 2020, we retrospectively reviewed 358 severe TBI patients who underwent CTA at admission and reexamination. CTA data were evaluated for the presence of cerebrovascular changes, including cerebrovascular shift (CS), cerebral vasospasm (CVS), large artery occlusion (LAO), and deep venous system occlusion (DVSO). Medical records were reviewed for baseline clinical characteristics and the relationship between CTA changes and outcomes. Cerebrovascular changes were identified in 247 (69.0%) of 358 severe TBI patients; only 25 (10.12%) of them had poor outcomes, and 162 (65.6%) patients had a good recovery. Eighty-three (23.18%) patients were diagnosed with CVS, 10 (12.05%) had a good outcome, 57 (68.67%) had severe disability and 16 (19.28%) had a poor outcome. There were twenty-six (7.3%) patients who had LAO and thirty-one (8.7%) patients who had DVSO; no patients had good recovery regardless of whether they had the operation or not. Cerebrovascular injuries and changes are frequent after severe TBI and correlate closely with prognosis. CTA is an important tool in evaluating the severity, predicting the operation effect and prognosis, and guiding therapy for severe TBI. Well-designed, multicenter, randomized controlled trials are needed to evaluate the value of CTA for severe TBI in the future.

The neuroprotection of controlled decompression after traumatic epidural intracranial hypertension through suppression of autophagy via PI3K/Akt signaling pathway

Acute intracranial hypertension (AIH) is a common and tricky symptom that inflicts upon patients after traumatic brain injury (TBI). A variety of clinical options have been applied for the management of AIH, such as physiotherapy, medication, surgery and combination therapy. Specifically, controlled decompression (CDC) alleviates the extent of brain injury and reduces the incidence of a series of post-TBI complications, thereby enhancing the prognosis of patients suffering from acute intracranial hypertension. The objective of the present project is to illuminate the potential molecular mechanism that underlies the neuroprotective effects of CDC in a rat model of traumatic epidural intracranial hypertension (TEIH). Herein, we observed the functional recovery, the degree of brain edema, the level of apoptosis, the expressions of neuronal cell autophagy-related signaling pathway proteins (including Akt, p-Akt, LC3 and Beclin-1) in rat TEIH model at 24 h post-surgery. The results showed in comparison with rapid decompression (RDC), CDC reduced the degree of brain edema, diminished the level of cellular apoptosis and enhanced neurological function, and whereas the neuroprotective effect of CDC could be reversed by rapamycin (Rap). The expressions of Beclin-1 and LC3 in CDC group were significantly lower than those of RDC group, and the expression levels of these two proteins were significantly elevated after the addition of Rap. The expression of p-Akt in CDC group was considerably enhanced than RDC group. After the addition of LY294002, a PI3K/Akt pathway inhibitor, p-Akt protein expression was reduced, and the neuroprotective effect of the rats was markedly inhibited. Taken together, our data demonstrate the superior neuroprotective effect of CDC with regard to alleviating early brain edema, improving the neurological status, suppressing apoptosis and inhibiting neuronal autophagy via triggering PI3K/Akt signaling pathway.

Effects of diaphragm electrical stimulation in treating respiratory dysfunction on mechanical ventilation after intracerebral hemorrhage: A single-center retrospective study

Intracerebral hemorrhage (ICH) is a major cause of death and disability worldwide. The benefits of electrical stimulation in the treatment of respiratory dysfunction in patients on mechanical ventilation is unknown. Nevertheless, there is a dearth of evidence-based medical research concerning its clinical efficacy. From January 2019 to January 2023, every enrolled patients experienced respiratory dysfunction after ICH while being supported by mechanical ventilation. A total of 205 eligible patients were enrolled and then allocated into 2 groups: control group and observation group. 133 patients was selected and administered standard treatment as control group. Based on conventional treatment, other 72 patients were administered diaphragm electrical stimulation (DES) treatment. We examined information from current medical records, encompassing all initial data and predictive follow-up data, such as the weaning success rate, occurrence of ventilator-associated pneumonia (VAP), duration of stay in the intensive care unit (ICU) and hospital, expenses related to hospitalization, and mortality within 30 days. The baseline clinical data of the 2 groups did not exhibit any statistically significant disparities (all P > .05). The rate of successful weaning showed a significant increase in the DES group when compared to the control group (P = .025). In patients with respiratory dysfunction due to ICH, treatment with DES resulted in a significant reduction in the duration of invasive ventilation (9.8 ± 2.1 vs 11.2 ± 2.6, P < .01) and total ventilation time (9.8 ± 2.1 vs 11.2 ± 2.6, P < .01). It also led to a decrease in the length of stay in the ICU (15.67 ± 3.76 vs 17.53 ± 4.28, P = .002) and hospitalization cost (11500 vs 13600, P = .001). Additionally, DES treatment resulted in a lower incidence of VAP (73.61% vs 86.46%, P = .022) and improved 30-day mortality (P < .05), without any significant adverse effects. The findings of this research indicate that DESs have a positive impact on enhancing the rate of successful weaning and reducing the incidence of VAP. It decreases the duration of invasive ventilation and total ventilation time while also improving the mortality rate within 30 days. This therapy could offer a fresh alternative for respiratory impairment in patients undergoing mechanical ventilation.

Comparison of the effects of stepwise intracranial decompression and decompressive craniectomy in the treatment of severe traumatic brain injury: A randomized controlled trial

BACKGROUND

To compare the effects of stepwise intracranial decompression (SID) and decompressive craniectomy (DC) on severe traumatic brain injury.

METHODS

This prospective randomized study was conducted at The Third Affiliated Hospital of Soochow University. Ninety two patients were divided into 2 groups according to the random number table method. The study group received SID, whereas the control group received DC. The surgical time and intraoperative bleeding of the 2 groups of patients were recorded, neurological function and glasgow coma score before and after treatment in both groups, incidence of complications, prognostic situation, and levels of brain oxygen metabolism indicators before and after treatment.

RESULTS

Among the 92 patients who agreed, 46 were assigned to the study and control groups, and 6 patients were excluded. Finally, 86 patients were analyzed, including 43 in the study group and 43 in the control group. After treatment, the glasgow coma score scores of the 2 groups increased compared to before treatment; the study group had a higher score, The National Institutes of Health Stroke Scale score decreased compared to before treatment, and the study group had a lower score (P < .05). The incidence of complications in the study group (4.65%) was significantly lower than that in the control group (18.60%) (P < .05). The good prognosis rate of the research group (41.86%) was significantly higher than that of the control group (16.28%) (P < .05).

CONCLUSION

Compared with DC, using SID to treat severe traumatic brain injury can shorten surgical time and reduce intraoperative bleeding, more effectively improve patients neurological function and consciousness state, reduce the incidence of complications, and regulate brain oxygen metabolism status, which is beneficial for improving prognosis and ensuring a good outcome of the disease.

Controlled Decompression Alleviates Motor Dysfunction by Regulating Microglial Polarization via the HIF-1α Signaling Pathway in Intracranial Hypertension

Decompressive craniectomy (DC) is a major form of surgery that is used to reduce intracranial hypertension (IH), the most frequent cause of death and disability following severe traumatic brain injury (sTBI) and stroke. Our previous research showed that controlled decompression (CDC) was more effective than rapid decompression (RDC) with regard to reducing the incidence of complications and improving outcomes after sTBI; however, the specific mechanisms involved have yet to be elucidated. In the present study, we investigated the effects of CDC in regulating inflammation after IH and attempted to identify the mechanisms involved. Analysis showed that CDC was more effective than RDC in alleviating motor dysfunction and neuronal death in a rat model of traumatic intracranial hypertension (TIH) created by epidural balloon pressurization. Moreover, RDC induced M1 microglia polarization and the release of pro-inflammatory cytokines. However, CDC treatment resulted in microglia primarily polarizing into the M2 phenotype and induced the significant release of anti-inflammatory cytokines. Mechanistically, the establishment of the TIH model led to the increased expression of hypoxia-inducible factor-1α (HIF-1α); CDC ameliorated cerebral hypoxia and reduced the expression of HIF-1α. In addition, 2-methoxyestradiol (2-ME2), a specific inhibitor of HIF-1α, significantly attenuated RDC-induced inflammation and improved motor function by promoting M1 to M2 phenotype transformation in microglial and enhancing the release of anti-inflammatory cytokines. However, dimethyloxaloylglycine (DMOG), an agonist of HIF-1α, abrogated the protective effects of CDC treatment by suppressing M2 microglia polarization and the release of anti-inflammatory cytokines. Collectively, our results indicated that CDC effectively alleviated IH-induced inflammation, neuronal death, and motor dysfunction by regulating HIF-1α-mediated microglial phenotype polarization. Our findings provide a better understanding of the mechanisms that underlie the protective effects of CDC and promote clinical translational research for HIF-1α in IH.

Effects of remote ischemic preconditioning in severe traumatic brain injury: A single-center randomized controlled trial

BACKGROUND

Traumatic brain injury (TBI) is a significant contributor to global mortality and impairment. Experimental data has shown the advantages of remote ischemic preconditioning (RIPC) in treating brain injury, however, there is a lack of evidence-based medicine regarding its clinical effectiveness and safety.

MATERIALS AND METHODS

In this study, we investigated whether RIPC could enhance outcomes in patients with severe TBI. Between January 2019 and December 2022, a comprehensive assessment was conducted on 392 individuals with severe TBI. Out of these, 304 patients were initially included and randomly assigned to receive either RIPC treatment (n = 153) or a control treatment (n = 151). The main measures of results included Glasgow Outcome Scale scores at 6 months, the occurrence of cerebral infarction during hospitalization, mortality rate within 30 days, levels of neuron-specific enolase and S-100β, any adverse effects, expenses incurred during hospitalization, and duration of hospital stay.

RESULTS

The 2 groups did not show any statistically significant differences in baseline clinical data. The Glasgow Outcome Scale scores at 6 months in the RIPC group showed significant improvement when compared with the control group. Additionally, the application of RIPC therapy can reduce the concentrations of neuron-specific enolase and S-100β. There was no notable distinction observed between the 2 groups regarding the adverse reactions of RIPC-induced objective indications of tissue or neurovascular harm. In the RIPC group, there was a significant reduction in both the duration of hospital stays and the expenses associated with hospitalization.

CONCLUSION

The results of this study suggest that RIPC has the potential to enhance clinical outcomes, mitigate nerve damage, and reduce both hospital expenses and length of stay in patients with severe TBI. The use of RIPC is a reliable and efficient method for managing severe TBI.

Technical Optimization of Decompressive Craniectomy for Possible Conversion to Hinge Craniotomy in Traumatic Brain Injury

Hinge craniotomy for the management of elevated intracranial pressure (ICP) in traumatic brain injury remains a technique not widely adopted. The hinged bone flap decreases the allowable intracranial volume expansion, which can lead to persistent post-operative elevated ICP and the need for salvage craniectomy. Herein, we describe the technical nuances in performing a decompressive craniectomy that, when optimized, allows for stronger consideration for hinge craniotomy as a definitive technique. To conclude, hinge craniotomy is a reasonable option in the setting of traumatic brain injury. Trauma neurosurgeons can consider the technical steps to optimize a decompressive craniectomy and perform hinge craniotomy when allowable.

Omega-3 polyunsaturated fatty acids alleviate early brain injury after traumatic brain injury by inhibiting neuroinflammation and necroptosis

Presently, traumatic brain injury (TBI) is a leading contributor to disability and mortality that places a considerable financial burden on countries all over the world. Docosahexaenoic acid and eicosapentaenoic acid are two kinds of omega-3 polyunsaturated fatty acids (ω-3 PUFA), both of which have been shown to have beneficial biologically active anti-inflammatory and antioxidant effects. However, the neuroprotective effect of ω-3 PUFA in TBI has not been proven, and its probable mechanism remains obscure. We suppose that ω-3 PUFA can alleviate early brain injury (EBI) via regulating necroptosis and neuroinflammation after TBI. This research intended to examine the neuroprotective effect of ω-3 and its possible molecular pathways in a C57BL/6 mice model of EBI caused by TBI. Cognitive function was assessed by measuring the neuronal necroptosis, neuroinflammatory cytokine levels, brain water content, and neurological score. The findings demonstrate that administration of ω-3 remarkably elevated neurological scores, alleviated cerebral edema, and reduced inflammatory cytokine levels of NF-κB, interleukin-1β (IL-1β), IL-6, and TNF-α, illustrating that ω-3 PUFA attenuated neuroinflammation, necroptosis, and neuronal cell death following TBI. The PPARγ/NF-κB signaling pathway is partially responsible for the neuroprotective activity of ω-3. Collectively, our findings illustrate that ω-3 can alleviate EBI after TBI against neuroinflammation and necroptosis.

Cerebrolysin alleviates early brain injury after traumatic brain injury by inhibiting neuroinflammation and apoptosis via TLR signaling pathway

Purpose:

Traumatic brain injury (TBI) is a major cause of death and disability. Cerebrolysin (CBL) has been reported to be anti-inflammatory by reducing reactive oxygen species (ROS) production. However, the neuroprotection of CBL in TBI and the potential mechanism are unclear. We aimed to investigate the neuroprotection and mechanisms of CBL in TBI.

Methods:

The TBI model was established in strict accordance with the Feeney weight-drop model of focal injury. The neurological score, brain water content, neuroinflammatory cytokine levels, and neuronal damage were evaluated. The involvement of the early brain injury modulatory pathway was also investigated.

Results:

Following TBI, the results showed that CBL administration increased neurological scores and decreased brain edema by alleviating blood‑brain barrier (BBB) permeability, upregulating tight junction protein (ZO‑1) levels, and decreasing the levels of the inflammatory cytokines tumor necrosis factor‑α (TNF‑α), interleukin‑1β (IL‑1β), IL‑6, and NF‑κB. The TUNEL assay showed that CBL decreased hippocampal neuronal apoptosis after TBI and decreased the protein expression levels of caspase‑3 and Bax, increasing the levels of Bcl‑2. The levels of Toll‑like receptor 2 (TLR2) and TLR4 were significantly decreased after CBL treatment. In TBI patients, CBL can also decrease TNF‑α, IL‑1β, IL‑6, and NF‑κB levels. This result indicates that CBL‑mediated inhibition of neuroinflammation and apoptosis ameliorated neuronal death after TBI. The neuroprotective capacity of CBL is partly dependent on the TLR signaling pathway.

Conclusions:

Taken together, the results of this study indicate that CBL can improve neurological outcomes and reduce neuronal death against neuroinflammation and apoptosis via the TLR signaling pathway in mice.

Controlled Decompression Alleviates Brain Injury via Attenuating Oxidative Damage and Neuroinflammation in Acute Intracranial Hypertension

BACKGROUND

The benefits of controlled decompression (CDC) for patients with acute intracranial hypertension especially in terms of alleviating the complications caused by rapid decompression (RDC) have been confirmed by clinical studies. This study is aimed at evaluating the therapeutic potency of CDC with ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) by investigating the potential molecular mechanism in the acute intracranial hypertension (AICH) rabbit model.

METHODS

Male New Zealand white rabbits were randomly subdivided into the sham-operated (SH) group, CDC group, and RDC group. Blood plasma samples and brain tissue were collected 2 days before operation (baseline) and at 3, 6, 24, and 72 hours after operation to measure the levels of UCH-L1, GFAP, oxidative stress indicators, and inflammatory cytokines by performing ELISA or Western blot. The neurological score of the rabbits and brain water content was graded 24 h after surgery. qPCR, immunofluorescence, and FJ-C staining were conducted.

RESULTS

CDC improved neurological function, lowered brain water content, ameliorated neuronal degeneration, attenuated oxidative damage, and inflammatory responses to a greater extent than RDC. Plasma UCH-L1 level was significantly lower in the CDC group at 3 h postoperatively than in the RDC group. CDC reduced plasma GFAP levels to various degrees at 3 h, 6 h, and 24 h postoperatively compared with RDC. Immunofluorescence confirmed that the expression of UCH-L1 and GFAP in the cortex of the CDC group was lower than that of the RDC group.

CONCLUSIONS

Our data collectively demonstrate that CDC could attenuate oxidative damage and inflammatory responses, downregulate UCH-L1 and GFAP levels, and contribute to an improved neuroprotective effect compared with RDC.

Hydrogen-rich saline alleviates early brain injury through inhibition of necroptosis and neuroinflammation via the ROS/HO-1 signaling pathway after traumatic brain injury

Traumatic brain injury (TBI) has been recognized as a serious public health issue and a key contributor to disability and death, with a huge economic burden worldwide. Hydrogen, which is a slight and specific cytotoxic oxygen radical scavenger, has been demonstrated to ameliorate early brain injury (EBI) through reactive oxygen species (ROS), oxidative stress injury, apoptosis and necroptosis. Necroptosis refers to a type of programmed cell death process that has a vital function in neuronal cell death following TBI. The specific function of necroptosis in hydrogen-mediated neuroprotection after TBI, however, has yet to be determined. The present study aimed to examine the neuroprotective effects and possible molecular basis that underly hydrogen-rich saline in TBI-stimulated EBI by examining neural necroptosis in the C57BL/6 mouse model. The brain water content, neurological score, neuroinflammatory cytokines (NF-κΒ, TNF-α, IL-6 and IL-1β) and ROS were evaluated using flow cytometry. Malondialdehyde, superoxide dismutase (SOD) and glutathione (GSH) levels were evaluated using a biochemical kit. Receptor-interacting protein kinase (RIP)1, RIP3, Nrf2 and Heme oxygenase-1 (HO-1) were evaluated using western blotting. mRNA of Nrf2 and HO-1 were evaluated using quantitative PCR. Neuronal death was evaluated by TUNEL staining. The outcomes illustrated that hydrogen-rich saline treatment considerably enhanced the neurological score, increased neuronal survival, decreased the levels of serum MDA and brain ROS, increased the levels of serum GSH and SOD. In addition the protein expression levels of RIP1 and RIP3 and the cytokines NF-κB, TNF-α, IL-1β and IL-6 were downregulated compared with the TBI group, which demonstrated that hydrogen-rich saline-induced inhibition of necroptosis and neuroinflammation ameliorated neuronal death following TBI. The neuroprotective capacity of hydrogen-rich saline was demonstrated to be partly dependent on the ROS/heme oxygenase-1 signaling pathway. Taken together, the findings of the present study indicated that hydrogen-rich saline enhanced neurological outcomes in mice and minimized neuronal death by inducing protective effects against neural necroptosis as well as neuroinflammation.

Ulinastatin alleviates early brain injury after traumatic brain injury by inhibiting oxidative stress and apoptosis

Purpose:

Traumatic brain injury (TBI) remains a major public health problem and cause of death. Ulinastatin (UTI), a serine protease inhibitor, has been reported to have an anti-inflammatory effect and play a role in immunoregulation and organ protection by reducing reactive oxygen species (ROS) production, oxidative stress and inflammation. However, the neuroprotective of UTI in TBI has not been confirmed. Therefore, this study aimed to investigate the neuroprotection and potential molecular mechanisms of UTI in TBI-induced EBI in a C57BL/6 mouse model.

Methods:

The neurological score and brain water content were evaluated. Enzyme-linked immunosorbent assay was used to detect neuroinflammatory cytokine levels, ROS and malondialdehyde detection to evaluate oxidative stress levels, and TUNEL staining and western blotting to examine neuronal damages and their related mechanisms.

Results:

Treatment with UTI markedly increased the neurological score; alleviated brain oedema; decreased the inflammatory cytokine tumour necrosis factor a, interleukin-1β (IL-1β), IL-6 and nuclear factor kappa B (NF-kB) levels; inhibited oxidative stress; decreased caspase-3 and Bax protein expressions; and increased the Bcl-2 levels, indicating that UTI-mediated inhibition of neuroinflammation, oxidative stress and apoptosis ameliorated neuronal death after TBI. The neuroprotective capacity of UTI is partly dependent on the TLR4/NF-kB/p65 signalling pathway.

Conclusions:

Therefore, this study reveals that UTI improves neurological outcomes in mice and reduces neuronal death by protecting against neural neuroinflammation, oxidative stress and apoptosis.

Controlled decompression attenuates brain damage in a rat model of epidural extreme intracranial hypertension: Partially via inhibiting necroptosis and inflammatory response

Intracranial hypertension (IH) remains a common symptom of neurological diseases, and requires stepwise treatments to release intracranial pressure (ICP). In the present study, we built a rat model of epidural extreme intracranial hypertension (EEIH) and verified the effectiveness of a surgery method called controlled decompression on attenuating brain injury induced by EEIH. For the model part, we determined the level of EEIH of rats via recording ICP and cerebral perfusion pressure (CPP) and the variation tendency of survival rates, mean blood artery pressure and mean velocity (Vm) of left middle cerebral artery (LMCA) as ICP ascending. SD rats were assigned into 4 groups: Sham group, Controlled decompression group (Con group), Rapid decompression group (Rap group) and Rapid decompression + Necrostatin-1 (Nec-1) group (Rap+Nec-1 group). The results suggested that controlled decompression lowered cerebral water content, improved neurological function, and attenuated EEIH-induced inflammation response and ROS generation to a greater extent than rapid decompression. Meanwhile, controlled decompression functioned to preserve more Nissl bodies, indicating alleviated neuron injury after EEIH. Additionally, the permeability of blood brain barrier (BBB) was also safeguarded in the Con group. Western blotting (WB) and Real-time Polymerase Chain Reaction (rt-PCR) assays consistently determined lower protein and mRNA levels of necroptosis-related molecules receptor interacting protein kinase 1 (RIPK1), interacting protein kinase 3 (RIPK3) and mixed lineage kinase domain-like protein (MLKL) (WB only) in the Con and Rap+Nec-1 group. Double immunofluorescent staining found weaker fluorescence intensity of RIPK3 in the compressed cortex of the Con and Rap+Nec-1 group.

Controlled Decompression Attenuates Compressive Injury following Traumatic Brain Injury via TREK-1-Mediated Inhibition of Necroptosis and Neuroinflammation

Decompressive craniectomy is an effective strategy to reduce intracranial hypertension after traumatic brain injury (TBI), but it is related to many postoperative complications, such as delayed intracranial hematoma and diffuse brain swelling. Our previous studies have demonstrated that controlled decompression (CDC) surgery attenuates brain injury and reduces the rate of complications after TBI. Here, we investigated the potential molecular mechanisms of CDC in experimental models. The in vitro experiments were performed in a traumatic neuronal injury (TNI) model following compression treatment in primary cultured cortical neurons. We found that compression aggravates TNI-induced neuronal injury, which was significantly attenuated by CDC for 2 h or 3 h. The results of immunocytochemistry showed that CDC reduced neuronal necroptosis and activation of RIP3 induced by TNI and compression, with no effect on RIP1 activity. These protective effects were associated with decreased levels of inflammatory cytokines and preserved intracellular Ca²⁺ homeostasis. In addition, the expression of the two-pore domain K⁺ channel TREK-1 and its activity was increased by compression and prolonged by CDC. Treatment with the TREK-1 blockers, spadin or SID1900, could partially prevent the effects of CDC on intracellular Ca²⁺ metabolism, necroptosis, and neuronal injury following TNI and compression. Using a traumatic intracranial hypertension model in rats, we found that CDC for 20 min or 30 min was effective in alleviating brain edema and locomotor impairment in vivo. CDC significantly inhibited neuronal necroptosis and neuroinflammation and increased TREK-1 activation, and the CDC-induced protection in vivo was attenuated by spadin and SID1900. In summary, CDC is effective in alleviating compressive neuronal injury both in vitro and in vivo, which is associated with the TREK-1-mediated attenuation of intracellular Ca²⁺ overload, neuronal necroptosis, and neuroinflammation.

Spectrum of remote site extradural hematomas following decompressive craniectomy: Does fracture always co-exist?

Background

Remote-site extradural hematomas (EDHs) after decompressive-surgeries for traumatic brain injury (TBI) are rarely encountered. Typically, they form contralateral to the injured side, with an overlying fracture. We present a subset which developed EDH immediately after decompressive-hemi-craniectomy for TBI, most without an evidence of fracture, and not limited to contralateral location.

Methods

Nine such patients were retrospectively identified. Plausible mechanisms, management issues and outcomes have been discussed.

Results

All nine patients were victims of severe-TBI. Six did not have any skull-fractures. Eight showed hemispheric-injuries while one had bifrontal-contusions. In hemispheric-injuries, midline-shift was at least 8 mm except one with midline-shift of 6 mm. The EDH was straddling the midline in 2 (bifrontal-1, bi-occipital-1), and juxtaposed to the previous craniectomy in 1, apart from a contralateral-bleed in 6; all, except one, needed evacuation. In most patients, venous-source of bleed was identified. All had improved from their preoperative Glasgow coma scale (GCS) at follow-up.

Conclusion

A fracture need not always co-exist in EDH following decompressive craniectomy. However, an extra-caution is suggested in its presence. Given the need for surgical-evacuation in most patients and an inability to assess immediate postoperative-GCS in severely head-injured, a routine postoperative-computed tomography is recommended to avoid overlooking such potentially treatable condition.

Vacuum Drains versus Passive Drains versus No Drains in Decompressive Craniectomies-A Randomized Controlled Trial on Subgaleal Drain Complication Rates (VADER Trial)

OBJECTIVE

Subgaleal drains are generally deemed necessary for cranial surgeries including decompressive craniectomies (DCs) to avoid excessive postoperative subgaleal hematoma (SGH) formation. Many surgeries have moved away from routine prophylactic drainage but the role of subgaleal drainage in cranial surgeries has not been addressed.

METHODS

This was a randomized controlled trial at 2 centers. A total of 78 patients requiring DC were randomized in a 1:1:1 ratio into 3 groups: vacuum drains (VD), passive drains (PD), and no drains (ND). Complications studied were need for surgical revision, SGH amount, new remote hematomas, postcraniectomy hydrocephalus (PCH), functional outcomes, and mortality.

RESULTS

Only 1 VD patient required surgical revision to evacuate SGH. There was no difference in SGH thickness and volume among the 3 drain types (P = 0.171 and P = 0.320, respectively). Rate of new remote hematoma and PCH was not significantly different (P = 0.647 and P = 0.083, respectively), but the ND group did not have any patient with PCH. In the subgroup analysis of 49 patients with traumatic brain injury, the SGH amount of the PD and ND group was significantly higher than that of the VD group. However, these higher amounts did not translate as a significant risk factor for poor functional outcome or mortality. VD may have better functional outcome and mortality.

CONCLUSIONS

In terms of complication rates, VD, PD, and ND may be used safely in DC. A higher amount of SGH was not associated with poorer outcomes. Further studies are needed to clarify the advantage of VD regarding functional outcome and mortality, and if ND reduces PCH rates.

Dexmedetomidine alleviates early brain injury following traumatic brain injury by inhibiting autophagy and neuroinflammation through the ROS/Nrf2 signaling pathway

Traumatic brain injury (TBI) is a major public health problem and a major cause of mortality and disability that imposes a substantial economic burden worldwide. Dexmedetomidine (DEX), a highly selective α-2-adrenergic receptor agonist that functions as a sedative and analgesic with minimal respiratory depression, has been reported to alleviate early brain injury (EBI) following traumatic brain injury by reducing reactive oxygen species (ROS) production, apoptosis and autophagy. Autophagy is a programmed cell death mechanism that serves a vital role in neuronal cell death following TBI. However, the precise role of autophagy in DEX-mediated neuroprotection following TBI has not been confirmed. The present study aimed to investigate the neuroprotective effects and potential molecular mechanisms of DEX in TBI-induced EBI by regulating neural autophagy in a C57BL/6 mouse model. Mortality, the neurological score, brain water content, neuroinflammatory cytokine levels, ROS production, malondialdehyde levels and neuronal death were evaluated by TUNEL staining, Evans blue extravasation, ELISA, analysis of ROS/lipid peroxidation and western blotting. The results showed that DEX treatment markedly increased the survival rate and neurological score, increased neuron survival, decreased the expression of the LC3, Beclin-1 and NF-κB proteins, as well as the cytokines IL-1β, IL-6 and TNF-α, which indicated that DEX-mediated inhibition of autophagy and neuroinflammation ameliorated neuronal death following TBI. The neuroprotective capacity of DEX is partly dependent on the ROS/nuclear factor erythroid 2-related factor 2 signaling pathway. Taken together, the results of the present study indicated that DEX improves neurological outcomes in mice and reduces neuronal death by protecting against neural autophagy and neuroinflammation.

Controlled decompression alleviates early brain injury in rabbit intracranial hypertension model by regulating apoptosis/necroptosis

Purpose

To evaluate the effects of controlled decompression and rapid decompression, explore the potential mechanism, provide the theoretical basis for the clinical application, and explore the new cell death method in intracranial hypertension.

Methods

Acute intracranial hypertension was triggered in rabbits by epidural balloon compression. New Zealand white rabbits were randomly put into the sham group, the controlled decompression group, and the rapid decompression group. Brain water content, etc., was used to evaluate early brain injury. Western blotting and double immunofluorescence staining were used to detect necroptosis and apoptosis.

Results

Brain edema, neurological dysfunction, and brain injury appeared after traumatic brain injury (TBI). Compared with rapid decompression, brain water content was significantly decreased, neurological scores were improved by controlled decompression treatment. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining and Nissl staining showed neuron death decreased in the controlled decompression group. Compared with rapid decompression, it was also found that apoptosis-related protein caspase-3/ tumor necrosis factor (TNF)-a was reduced markedly in the brain cortex and serum, and the expression levels of necroptosis-related protein, receptor-interacting protein 1 (RIP1)/receptor-interacting protein 1 (RIP3) reduced significantly in the controlled decompression group.

Conclusions

Controlled decompression can effectively reduce neuronal damage and cerebral edema after craniocerebral injury and, thus, protect the brain tissue by alleviating necroptosis and apoptosis.

Malignant middle cerebral artery infarction following subacute subdural hematoma: A case report and literature review

Background:

Subacute subdural hematomas (ASDH) are only treated surgically when they cause mass effect significant enough to give symptoms. Rarely, sub-ASDH may cause enough pressure to result in a malignant middle cerebral artery (MCA) territory infarction. Decompressive craniectomy (DC) is the last resort to reduce intracranial pressure following malignant MCA infarction. Herein, we review the literature and describe a case of MCA/posterior cerebral artery (PCA) territories infarction following drainage of a sub-ASDH that was treated with DC with good outcome.

Case Description:

We report a case of malignant right-sided MCA/PCA infarction in a 62-year-old man who presented with progressive headache following a cycling incident leading to a head injury. Initial CT head demonstrated a small right ASDH. He had no neurological deficit, headache settled on analgesia, and there was no expansion of the SDH on the repeat CT; therefore, he was managed conservatively. He was admitted 6-days later with worsening headaches and hyponatremia. Repeat CT revealed an increase in size of the hematoma and mass effect leading to a mini-craniotomy and evacuation of hematoma. He developed left-sided hemiplegia, slurred speech and hyponatremia, and CT head demonstrated a right-sided MCA/PCA infarction with significant mass effect. He underwent emergent DC and subsequent cranioplasty and ultimately recovered to mRS of 2.

Conclusion:

SDH are frequent neurosurgical entities. Malignant MCA/PCA strokes following mini-craniotomies are rare but need to be considered especially during the consent process.

Decompressive Craniectomy in Traumatic Brain Injury-Craniectomy-Related and Cranioplasty-Related Complications in a Single Center

OBJECTIVE

Decompressive craniectomy (DC) relieves intracranial hypertension after severe traumatic brain injury (TBI), but it has been associated with poor clinical outcome in 2 recent randomized controlled trials. In this study, we investigated the incidence and explanatory variables for DC-related and cranioplasty (CP)-related complications after TBI.

METHODS

In this retrospective study, we identified 61 patients with TBI who were treated with DC in the neurointensive care unit, Uppsala University Hospital, Sweden, between 2008 and 2018. Demography, admission status, radiology, and clinical outcome were analyzed.

RESULTS

Eleven patients (18%) were reoperated because of postoperative hemorrhage after DC. Six (10%) developed postoperative infection during neurointensive care. Twenty-eight (46%) developed subdural hygromas and 10 (16%) received a permanent cerebrospinal fluid shunt. Sixteen patients (26%) died before CP. Median time to CP was 7 months (range, 2-19 months) and 32 (71%) were operated on with autologous bone and 13 (29%) with synthetic material primarily. In 9 patients with autologous bone (29%), the CP had to be replaced because of bone resorption/infection, whereas this did not occur after synthetic material (P = 0.04). However, all 4 postoperative hemorrhages after CP occurred when synthetic material was used (P = 0.005).

CONCLUSIONS

DC and CP surgery have a high risk for complications, leading to additional neurosurgery in about one third of cases. Synthetic CP materials may decrease the risk of reoperation, but special care with hemostasis is required because of increased risk of postoperative hemorrhage. Future trials need to address these topics to further improve the outcome for these patients.