Explore the vast range of titles available.

The in-hospital treatment of patients with traumatic brain injury (TBI) is considered to be expensive, especially in patients with severe TBI (s-TBI). To improve future treatment decision-making, resource allocation and research initiatives, this study reviewed the in-hospital costs for patients with s-TBI and the quality of study methodology. A systematic search was performed using the following databases: PubMed, MEDLINE, Embase, Web of Science, Cochrane library, CENTRAL, Emcare, PsychINFO, Academic Search Premier and Google Scholar. Articles published before August 2018 reporting in-hospital acute care costs for patients with s-TBI were included. Quality was assessed by using a 19-item checklist based on the CHEERS statement. Twenty-five out of 2372 articles were included. In-hospital costs per patient were generally high and ranged from $2,130 to $401,808. Variation between study results was primarily caused by methodological heterogeneity and variable patient and treatment characteristics. The quality assessment showed variable study quality with a mean total score of 71% (range 48% - 96%). Especially items concerning cost data scored poorly (49%) because data source, cost calculation methodology and outcome reporting were regularly unmentioned or inadequately reported. Healthcare consumption and in-hospital costs for patients with s-TBI were high and varied widely between studies. Costs were primarily driven by the length of stay and surgical intervention and increased with higher TBI severity. However, drawing firm conclusions on the actual in-hospital costs of patients sustaining s-TBI was complicated due to variation and inadequate quality of the included studies. Future economic evaluations should focus on the long-term cost-effectiveness of treatment strategies and use guideline recommendations and common data elements to improve study quality.

Background/Objectives: The co-existence of multiple compression sites on the same nerve can pose a clinical and diagnostic challenge, warranting a different treatment strategy. This so-called double crush syndrome (DCS) has mainly been investigated in the upper limb. Only a few studies have investigated DCS for the lower limb. In this article, a single-center illustrative clinical case series is presented, and current literature on L5 nerve root (NR) and concomitant common peroneal nerve (CPN) is reviewed. Methods: All patients presenting between 2019 and 2022 with L5 nerve root (NR) compression and, along their clinical courses, concomitant compression of the common peroneal nerve (CPN) at the fibular head were included. Information on clinical features, diagnostics and surgeries was obtained. The outcome was assessed at the last outpatient follow-up appointment. In addition, an extensive literature review has been conducted. Results: Fourteen patients were included with a mean follow-up of 6.8 months. The majority had pain (71%) or motor deficits (71%). Seven patients were referred for clinical and radiological L5 NR compression but were also found to have CPN compression; the other seven patients had persisting or recurrent symptoms after surgically or conservatively treated L5 NR compression, suggestive of additional peroneal neuropathy. All patients had CPN decompression at the fibular head, with successful results obtained in 93% of the patients. Pain of the lower leg improved in all patients, and dorsiflexion function improved in 78%. Conclusions: Concomitant L5 NR and CPN appear to occur more frequently than expected. Peroneal neuropathy can present simultaneously with L5 nerve radiculopathy or after surgically or conservatively treated L5 NR compression. Overlapping symptoms and variation in clinical presentations make it difficult to diagnose and, therefore, underrecognized. More awareness among treating physicians of this specific double crush syndrome is important to prevent any delay in treatment, in this case, a less invasive common peroneal nerve release at the fibular head, and to avoid unnecessary (additional) spinal surgery.

Background The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH Methods In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024. Discussion The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered. Trial registration Nederlands Trial Register (NTR), Trial NL9012 . ClinicalTrials.gov, Trial NCT04648436 .

Background Traumatic brain injury (TBI) is a major cause of death and disability across all ages. After the primary impact, the pathophysiologic process of secondary brain injury consists of a neuroinflammation response that critically leads to irreversible brain damage in the first days after the trauma. A key catalyst in this inflammatory process is the complement system. Inhibiting the complement system could therefore be a therapeutic target in TBI. Objective To study the safety and efficacy of C1-inhibitor (C1-INH) compared to placebo in patients with TBI. By temporarily blocking the complement system, we hypothesize a decrease in the posttraumatic neuroinflammatory response resulting in a less unfavorable clinical outcome for TBI patients. Methods CIAO@TBI is a multicenter, randomized, blinded, phase II placebo-controlled trial. Adult TBI patients with GCS < 13 requiring intracranial pressure (ICP) monitoring will be randomized, using block randomization, within 12 h after trauma to one dose 6000 IU C1-INH or placebo. A total of 106 patients will be included, and follow-up will occur up to 12 months. The primary endpoints are (1) Therapy Intensity Level (TIL) Scale, (2) Glasgow Outcome Scale-Extended (GOSE) at 6 months, and (3) complication rate during hospitalization. Outcomes will be determined by a trial nurse blinded for the treatment allocation. Analyses will be conducted in an intention-to-treat analysis. Discussion We expect that C1-INH administration will be safe and potentially effective to improve clinical outcomes by reducing neuroinflammation in TBI patients. Trial registration ClinicalTrials.gov NCT04489160. Registered on 27 July 2020. EudraCT 2020-000140-58

IntroductionControversy exists about the optimal treatment for patients with a traumatic acute subdural haematoma (ASDH) and an intracerebral haematoma/contusion (t-ICH). Treatment varies largely between different regions. The effect of this practice variation on patient outcome is unknown. Here, we present the protocol for a prospective multicentre observational study aimed at comparing the effectiveness of different treatment strategies in patients with ASDH and/or t-ICH. Specifically, the aims are to compare (1) an acute surgical approach to an expectant approach and (2) craniotomy to decompressive craniectomy when evacuating the haematoma.Methods and analysisPatients presenting to the emergency room with an ASDH and/or an t-ICH are eligible for inclusion. Standardised prospective data on patient and injury characteristics, treatment and outcome will be collected on 1000 ASDH and 750 t-ICH patients in 60–70 centres within two multicentre prospective observational cohort studies: the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) and Neurotraumatology Quality Registry (Net-QuRe). The interventions of interest are acute surgery, defined as surgery directly after the first CT at presentation versus late or no surgery and craniotomy versus decompressive craniectomy. The primary outcome measure is the Glasgow Outcome Score-Extended at 6 months. Secondary outcome measures include in-hospital mortality, quality of life and neuropsychological tests. In the primary analysis, the effect of treatment preference (eg, proportion of patients in which the intervention under study is preferred) per hospital will be analysed with random effects ordinal regression models, adjusted for casemix and stratified by study. Such a hospital-level approach reduces confounding by the indication. Sensitivity analyses will include propensity score matching, with treatment defined on patient level. This study is designed to determine the best acute management strategy for ASDH and t-ICH by exploiting the existing between-hospital variability in surgical management.Ethics and disseminationEthics approval was obtained in all participating countries. Results of surgical management of ASDH and t-ICH/contusion will separately be submitted for publication in a peer-reviewed journal.Trial registration number NCT02210221 and NL 5761.

[This corrects the article DOI: 10.1371/journal.pone.0216743.].

Background Surgical treatment options for meralgia paresthetica include neurolysis and neurectomy procedures. Reported success rates for pain relief are generally higher after neurectomy, but an obvious disadvantage compared with neurolysis is the loss of sensation in the anterolateral part of the thigh. In this study we analyzed our results on pain relief after both procedures, and we determined the impact of loss of sensation with a questionnaire. Methods Between 1999 and 2009, all patients with persistent symptoms of meralgia paresthetica who presented to our clinic after failure of conservative treatment were offered a neurectomy procedure. After this period, the surgical strategy was changed to first neurolysis followed by neurectomy in case of failure. We retrospectively analyzed our results for both strategies with a questionnaire that was focused on pain relief, numbness and the impact of numbness. Results Ten patients underwent a neurolysis with a 60 % pain relief rate compared to 87.5 % of the eight patients that primarily underwent a neurectomy. Most neurectomy patients (62.5 %) were not hindered by the numbness, 25 % sometimes and only one patient was frequently bothered, but was still satisfied with the outcome. The failures of neurolysis were secondarily treated by neurectomy, which resulted in pain relief in three out of four patients. Conclusions This series confirms previous reports in the literature that have shown higher success rates for the neurectomy procedure. In addition, it shows that most patients are not bothered by the numbness following this procedure. These observations can be used in the surgical decision making for meralgia paresthetica.

Several recent global traumatic brain injury (TBI) initiatives rely on practice variation in diagnostic and treatment methods to answer effectiveness questions. One of these scientific dilemmas, the surgical management of the traumatic acute subdural hematoma (ASDH) might be variable among countries, among centers within countries, and even among neurosurgeons within a center, and hence be amenable for a comparative effectiveness study. The aim of our questionnaire, therefore, was to explore variations in treatment for ASDH among neurosurgeons in similar centers in a densely populated geographical area. An online questionnaire, involving treatment decisions on six case vignettes of ASDH, was sent to 93 neurosurgeons in The Netherlands and Belgium. Clinical and radiological variables differed per case. Sixty neurosurgeons filled out the questionnaire (response rate 65%). For case vignettes with severe TBI and an ASDH, there was a modest variation in the decision to evacuate the hematoma and a large variation in the decision to combine the evacuation with a decompressive craniectomy. The main reasons for operating were “neurological condition” and “mass effect.” For ASDH and mild/moderate TBI, there was large variation in the decision of whether to operate or not, whereas “hematoma size” was the predominant motivation for surgery. Significant inter-center variation for the decision to evacuate the hematoma was observed (p = 0.01). Most pronounced was that 1 out of 7 (14%) neurosurgeons in one region chose a surgical strategy compared with 9 out of 10 (90%) in another region for the same scenario. In conclusion, variation exists in the neurosurgical management of TBI within an otherwise homogeneous setting. This variation supports the methodology of the international Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) initiative, and shaped the Dutch Neurotraumatology Quality Registry (Net-QuRe) initiative.

PurposeEvidence regarding the effect of surgery in traumatic intracerebral hematoma (t-ICH) is limited and relies on the STITCH(Trauma) trial. This study is aimed at comparing the effectiveness of early surgery to conservative treatment in patients with a t-ICH.MethodsIn a prospective cohort, we included patients with a large t-ICH (< 48 h of injury). Primary outcome was the Glasgow Outcome Scale Extended (GOSE) at 6 months, analyzed with multivariable proportional odds logistic regression. Subgroups included injury severity and isolated vs. non-isolated t-ICH.ResultsA total of 367 patients with a large t-ICH were included, of whom 160 received early surgery and 207 received conservative treatment. Patients receiving early surgery were younger (median age 54 vs. 58 years) and more severely injured (median Glasgow Coma Scale 7 vs. 10) compared to those treated conservatively. In the overall cohort, early surgery was not associated with better functional outcome (adjusted odds ratio (AOR) 1.1, (95% CI, 0.6–1.7)) compared to conservative treatment. Early surgery was associated with better outcome for patients with moderate TBI and isolated t-ICH (AOR 1.5 (95% CI, 1.1–2.0); P value for interaction 0.71, and AOR 1.8 (95% CI, 1.3–2.5); P value for interaction 0.004). Conversely, in mild TBI and those with a smaller t-ICH (< 33 cc), conservative treatment was associated with better outcome (AOR 0.6 (95% CI, 0.4–0.9); P value for interaction 0.71, and AOR 0.8 (95% CI, 0.5–1.0); P value for interaction 0.32).ConclusionsEarly surgery in t-ICH might benefit those with moderate TBI and isolated t-ICH, comparable with results of the STITCH(Trauma) trial.

[...]Beucler suggests that delayed surgery could be regarded as acute surgery and should not have been analysed in the conservative treatment group. The SHE score is a prediction tool that should not be used to triage treatment—the extensively validated IMPACT and CRASH-CT models are superior in this respect. [...]the SHE score has limited value as a prediction tool for acute subdural haematoma because 31% of the cohort in that study had mixed-acuity or chronic subdural haematoma.2 Therefore, the SHE score does not support an approach to limit treatment for older patients with acute subdural haematoma, with best available evidence suggesting the opposite.3–5 Third, Beucler presumes a benefit of primary decompressive craniectomy over craniotomy to account for the absence of benefit of acute surgery. Since treatment allocation was based on neurosurgeon preference, the effect estimate is applicable to patients for whom the neurosurgeon would consider both treatment options.