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Valle D, Villarreal XP, Lunny C, Chalamgari A, Wajid M, Mahmood A, Buthani S, Lucke-Wold B. Surgical Management of Neurotrauma: When to Intervene. JOURNAL OF CLINICAL TRIALS AND REGULATIONS 2022; 4:41-55. [PMID: 36643025 PMCID: PMC9840531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Neurotrauma, often defined as abrupt damage to the brain or spinal cord, is a substantial cause of mortality and morbidity that is widely recognized. As such, establishing an effective course of action is crucial to the enhancement of neurotrauma guidelines and patient outcomes in healthcare worldwide. Following the onset of neurotraumatic injuries, time is perhaps the most critical facet in diminishing mortality and morbidity rates. Thus, procuring the airway should be of utmost priority in a patient to allow for optimal ventilation, with a shift in focus resorting to surgical interventions after the patient reaches a suitable care facility. In particular, ventriculoperitoneal shunt (VPS) procedures have long been utilized to treat traumatic brain and spinal cord injuries to direct additional cerebrospinal fluid (CSF) from the lateral ventricles through a ventricular catheter attached to a valve that is further connected to a distal catheter. Decompressive cranio omie (DCs), cranioplasties, and intracranial pressure measurements (ICP) are also frequently performed in combination with VPS to manage intracranial hypertension and cerebral edema. Although the current surgical methods utilized in the treatment of neurotrauma prove to be highly efficacious in the prevention of adverse outcomes, emergent therapies are growing in popularity. Of interest, the Three Pillars Expansive Craniotomy, cisternostomy, and external lumbar drainages are cutting-edge procedures with promising results that can potentially usher change in the neurosurgical industry but require additional examination.
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Affiliation(s)
- Daisy Valle
- Post Graduate Student, Department of Neurosurgery, University of Florida, Florida, United States
| | - Xuban Palau Villarreal
- Post Graduate Student, Department of Neurosurgery, University of Florida, Florida, United States
| | - Caroline Lunny
- Post Graduate Student, Department of Neurosurgery, University of Florida, Florida, United States
| | - Anjalika Chalamgari
- Post Graduate Student, Department of Neurosurgery, University of Florida, Florida, United States
| | - Manahil Wajid
- Post Graduate Student, Department of Neurosurgery, University of Florida, Florida, United States
| | - Arman Mahmood
- Post Graduate Student, Department of Neurosurgery, University of Florida, Florida, United States
| | - Siya Buthani
- Post Graduate Student, Department of Neurosurgery, University of Florida, Florida, United States
| | - Brandon Lucke-Wold
- Post Graduate Student, Department of Neurosurgery, University of Florida, Florida, United States
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Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
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Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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Khalili H, Niakan A, Ghaffarpasand F, Kiani A, Behjat R. Outcome Determinants of Decompressive Craniectomy in Patients with Traumatic Brain Injury; A Single Center Experience from Southern Iran. Bull Emerg Trauma 2017; 5:190-196. [PMID: 28795064 PMCID: PMC5547207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 06/06/2017] [Accepted: 06/29/2016] [Indexed: 06/07/2023] Open
Abstract
OBJECTIVE To investigate the determinants of outcome in patients with traumatic brain injury (TBI) undergoing decompressive craniectomy (DC) in a large level I trauma center in southern Iran. METHODS This retrospective cross-sectional study was conducted during an 18-month period from 2013 to 2014 in Shahid Rajaei hospital, a Level I trauma center in Southern Iran. Patients with TBI who had undergone DC were included and the medical charts were reviewed regarding demographics, clinical, radiological and outcome characteristics. The outcome was determined by extended Glasgow outcome scale (GOS-E) after one year of surgery. The variables were compared between those with favorable and unfavorable outcome to investigate the outcome determinants. RESULTS Overall 142 patients with mean age of 34.8 ± 15.5 (ranging from 15 to 85) years were included. There were 127 (89.4%) men and 15 (10.6%) women among the patients. After 1-year, the mortality rate was 58 (40.8%) and 8 (5.6%) patients were persistent vegetative state. The final outcome was found to be unfavorable in 77 (54.2%) patients. Unfavorable outcome was associated with lower GCS on admission (p<0.001) as well as occurrence of postoperative hydrocephalus (p=0.011). Formation of the postoperative subdural hygroma after the operation was found to be associated with favorable outcome (p=0.019). CONCLUSION DC in patients with TBI is associated with favorable outcome in most of them. On admission GCS, postoperative hydrocephalus and presence of postoperative subdural hygroma are among the important predictors of outcome in TBI patients undergoing DC.
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Affiliation(s)
- Hosseinali Khalili
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Niakan
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fariborz Ghaffarpasand
- Student Research Committee, Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arash Kiani
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Behjat
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
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Zhang M, Cui Z, Cui H, Cao Y, Zhong C, Wang Y. Astaxanthin alleviates cerebral edema by modulating NKCC1 and AQP4 expression after traumatic brain injury in mice. BMC Neurosci 2016; 17:60. [PMID: 27581370 PMCID: PMC5007682 DOI: 10.1186/s12868-016-0295-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/17/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Astaxanthin is a carotenoid pigment that possesses potent antioxidative, anti-inflammatory, antitumor, and immunomodulatory activities. Previous studies have demonstrated that astaxanthin displays potential neuroprotective properties for the treatment of central nervous system diseases, such as ischemic brain injury and subarachnoid hemorrhage. This study explored whether astaxanthin is neuroprotective and ameliorates neurological deficits following traumatic brain injury (TBI). RESULTS Our results showed that, following CCI, treatment with astaxanthin compared to vehicle ameliorated neurologic dysfunctions after day 3 and alleviated cerebral edema and Evans blue extravasation at 24 h (p < 0.05). Astaxanthin treatment decreased AQP4 and NKCC1 mRNA levels in a dose-dependent manner at 24 h. AQP4 and NKCC1 protein expressions in the peri-contusional cortex were significantly reduced by astaxanthin at 24 h (p < 0.05). Furthermore, we also found that bumetanide (BU), an inhibitor of NKCC1, inhibited trauma-induced AQP4 upregulation (p < 0.05). CONCLUSIONS Our data suggest that astaxanthin reduces TBI-related injury in brain tissue by ameliorating AQP4/NKCC1-mediated cerebral edema and that NKCC1 contributes to the upregulation of AQP4 after TBI.
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Affiliation(s)
- Mingkun Zhang
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127 China
| | - Zhenwen Cui
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, 266005 China
| | - Hua Cui
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127 China
| | - Yang Cao
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127 China
| | - Chunlong Zhong
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127 China
| | - Yong Wang
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127 China
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Bao HJ, Qiu HY, Kuai JX, Song CJ, Wang SX, Wang CQ, Peng HB, Han WC, Wu YP. Apelin-13 as a novel target for intervention in secondary injury after traumatic brain injury. Neural Regen Res 2016; 11:1128-33. [PMID: 27630697 PMCID: PMC4994456 DOI: 10.4103/1673-5374.187049] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The adipocytokine, apelin-13, is an abundantly expressed peptide in the nervous system. Apelin-13 protects the brain against ischemia/reperfusion injury and attenuates traumatic brain injury by suppressing autophagy. However, secondary apelin-13 effects on traumatic brain injury-induced neural cell death and blood-brain barrier integrity are still not clear. Here, we found that apelin-13 significantly decreases cerebral water content, mitigates blood-brain barrier destruction, reduces aquaporin-4 expression, diminishes caspase-3 and Bax expression in the cerebral cortex and hippocampus, and reduces apoptosis. These results show that apelin-13 attenuates secondary injury after traumatic brain injury and exerts a neuroprotective effect.
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Affiliation(s)
- Hai-jun Bao
- Department of Pathology, Xuzhou Medical College, Xuzhou, Jiangsu Province, China
| | - Hai-yang Qiu
- Department of Pathology, Xuzhou Medical College, Xuzhou, Jiangsu Province, China
| | - Jin-xia Kuai
- Department of Forensic Medicine, Xuzhou Medical College, Xuzhou, Jiangsu Province, China
| | - Cheng-jie Song
- Department of Physiology, Xuzhou Medical College, Xuzhou, Jiangsu Province, China
| | - Shao-xian Wang
- Department of Pathology, Xuzhou Medical College, Xuzhou, Jiangsu Province, China
| | - Chao-qun Wang
- Department of Pathology, Xuzhou Medical College, Xuzhou, Jiangsu Province, China
| | - Hua-bin Peng
- Department of Pathology, Xuzhou Medical College, Xuzhou, Jiangsu Province, China
| | - Wen-can Han
- Department of Pathology, Xuzhou Medical College, Xuzhou, Jiangsu Province, China
| | - Yong-ping Wu
- Department of Pathology, Xuzhou Medical College, Xuzhou, Jiangsu Province, China,Correspondence to: Yong-ping Wu, .
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Fotakopoulos G, Tsianaka E, Vagkopoulos K, Fountas KN. According to which factors in severe traumatic brain injury craniectomy could be beneficial. Surg Neurol Int 2016; 7:19. [PMID: 26981320 PMCID: PMC4774169 DOI: 10.4103/2152-7806.176671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 12/31/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To investigate the clinical outcome at 101 patients undergoing decompressive craniectomy (DC) after severe traumatic brain injury (TBI). METHODS Age, Glasgow Coma Scale (GCS) at the time of intubation, and the intraoperative intracranial pressure (ICP) were recorded. Formal DC was performed in all cases and the square surface of bone flap was calculated in cm(2) based on the length and the width from computed tomography scan. RESULTS The difference of good neurological recovery (Glasgow outcome score 4-5), between patients with ICP ≤20 mmHg, GCS ≥5, age ≤60 years, and bone flap ≥130 cm(2) and those with ICP >20 mmHg, GCS <5, age >60 years, and bone flap <130 cm(2), was statistically significant. CONCLUSION Although the application of DC in severe TBI is controversial and the population in this study is small, our study demonstrates the threshold of the specific factors (patient age, ICP and GCS on the day of the surgery and the size of the bone flap) which may help in the decision of performing DC. Furthermore, this study proves that the different combinations and mainly at the same time involvement of all prognostic parameters (age <60, GCS <5, bone flap ≥130 cm(2), and ICP ≤20 at time of DC surgery) allow a better outcome.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece,Corresponding author
| | - Eleni Tsianaka
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Konstantinos Vagkopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece,Center for Research and Technology of Thessaly, 38500 Larissa, Greece
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Bao HJ, Wang T, Zhang MY, Liu R, Dai DK, Wang YQ, Wang L, Zhang L, Gao YZ, Qin ZH, Chen XP, Tao LY. Poloxamer-188 attenuates TBI-induced blood-brain barrier damage leading to decreased brain edema and reduced cellular death. Neurochem Res 2012; 37:2856-67. [PMID: 23011204 DOI: 10.1007/s11064-012-0880-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 08/25/2012] [Accepted: 08/29/2012] [Indexed: 10/27/2022]
Abstract
Plasmalemma permeability plays an important role in the secondary neuronal death induced by traumatic brain injury (TBI). Previous works showed that Poloxamer 188 (P188) could restore the intactness of the plasma membrane and play a cytoprotective action. However, the roles of P188 in blood-brain barrier (BBB) integrity and TBI-induced neural cell death are still not clear. In this study, mice were induced TBI by controlled cortical impact (CCI), and cerebral water content was measured to explore the profile of brain edema after CCI. Further, the regimen of P188 in mouse CCI models was optimized. The neurological test and BBB integrity assessment were performed, and the numbers of TBI-induced neural cell death were counted by propidium iodide (PI) labeling. The expression of apoptotic pathway associated proteins (Bax, cyt-c, caspase-8, caspase-9, caspase-3, P53) and aquaporin-4 (AQP4) was assessed by RT-PCR or immunoblotting. The data showed that the brain edema peaked at 24 h after TBI in untreated animals. Tail intravenous injection of P188 (4 mg/ml, 100 μl) 30 min before TBI or within 30 min after TBI could attenuate TBI-induced brain edema. P188 pre-treatment restored BBB integrity, suppressed TBI-induced neural cell death, and improved neurological function. TBI induced an up-regulation of Bax, cyt-c, caspase-8, caspase-9, caspase-3, and the expression of p53 was down-regulated by P188 pre-treatment. AQP4 mainly located on endothelial cells and astrocytes, and its expression was also regulated by P188 pretreatment. All these results revealed that P188 attenuates TBI-induced brain edema by resealing BBB and regulating AQP4 expression, and suppressed apoptosis through extrinsic or intrinsic pathway. Plasmalemma permeability may be a potential target for TBI treatment.
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Affiliation(s)
- Hai-Jun Bao
- Institute of Forensic Sciences, Soochow University, Suzhou 215123, Jiangsu, China
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