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Intraparenchymal hemorrhages occur in a proportion of severe traumatic brain injury TBI patients, but the role of surgery in their treatment is unclear. This international multi-center, patient-randomized, parallel-group trial compared early surgery (hematoma evacuation within 12 h of randomization) with initial conservative treatment (subsequent evacuation allowed if deemed necessary). Patients were randomized using an independent randomization service within 48 h of TBI. Patients were eligible if they had no more than two intraparenchymal hemorrhages of 10 mL or more and did not have an extradural or subdural hematoma that required surgery. The primary outcome measure was the traditional dichotomous split of the Glasgow Outcome Scale obtained by postal questionnaires sent directly to patients at 6 months. The trial was halted early by the UK funding agency (NIHR HTA) for failure to recruit sufficient patients from the UK (trial registration: ISRCTN19321911). A total of 170 patients were randomized from 31 of 59 registered centers worldwide. Of 82 patients randomized to early surgery with complete follow-up, 30 (37%) had an unfavorable outcome. Of 85 patients randomized to initial conservative treatment with complete follow-up, 40 (47%) had an unfavorable outcome (odds ratio, 0.65; 95% confidence interval, CI 0.35, 1.21; p=0.17), with an absolute benefit of 10.5% (CI, −4.4–25.3%). There were significantly more deaths in the first 6 months in the initial conservative treatment group (33% vs. 15%; p=0.006). The 10.5% absolute benefit with early surgery was consistent with the initial power calculation. However, with the low sample size resulting from the premature termination, we cannot exclude the possibility that this could be a chance finding. A further trial is required urgently to assess whether this encouraging signal can be confirmed.

Background Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care. Methods A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted. Results A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided. Conclusions This consensus provides practical recommendations to support clinician’s decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.

ObjectiveTo evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI).MethodsA single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, “primary procedure” and “secondary procedure”, was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO2) values as well as the need for additional osmotherapy and CSF drainage.ResultsForty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average post-surgical ICP values, higher PbO2 values and required less osmotic treatments as compared with those treated with DC alone.ConclusionOur preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.

Objective The key to increasing the success rate of limb preservation lies in timely restoration of the blood supply to the severed limb, This study examines the clinical effect of a disposable intravenous infusion device as a temporary vascular shunt device which can quickly restore blood circulation in the replantation of severed limbs. Methods A retrospective review of all amputated major limbs in our department from May 2005 to May 2022. Patients treated with intravenous infusion tubes as temporary vascular shunt devices were included in group A(shunt group ) and those who could not use temporary intravascular shunt devices were included in group B (no shunt group). The durations of temporary vascular shunt placement and continuous placement during the operation were recorded, and the rates of limb survival and complications ( thrombosis and osteofascial compartment syndrome, infection) were evaluated after the operation. A comparison of complications, the postoperative function between the two groups was also performed. Results: A total of 67 patients were included: group A (shunt group, n  = 35) and group B (no shunt group, n  = 32), The average duration of temporary vascular shunt placement in all patients was 10 ± 1.5 min. The rate of amputation and the incidence of thrombus compartment syndrome and infection were statistically different between the two groups ( P  < 0.05), There was no significant difference in thrombosis rate between the two groups. All patients were followed up for a mean of 32.5 (8–60) months. The DASH scores of group A and group B at the last follow-up were 65 ± 8.5 points and 85 ± 6.5 points respectively and The Maryland foot scores of group A and group B at the last follow-up were 58 ± 4.5 points and 35 ± 5.5 points respectively, There were statistical differences in function between the two groups( P  < 0.05). Conclusion A disposable intravenous infusion device as a temporary vascular shunt device can be effectively and practically used for reducing the warm ischemia time and significantly improving the successful limb replantation rate and is therefore worthy of clinical application.

Background Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide. Method A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019. Results We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC. Conclusion Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial.

Background Decompressive craniectomy (DC) is a last-resort treatment for severe traumatic brain injury (TBI) with refractory intracranial hypertension. Randomized controlled trials (RCTs) report mixed and sometimes conflicting results, leaving uncertainties regarding indications, timing, and long-term benefits. This study explored DC practices and outcomes in a contemporary Swedish setting contextualised in modern RCT evidence. Methods This retrospective multicentre study included 299 TBI patients who underwent DC between 2008 and 2022 across four Swedish neurosurgical centres. Clinical, radiological, surgical, and outcome data (6-months Glasgow Outcome Scale) were collected. Differences across centres and between adults/children were analysed. Results Annual DC rate remained stable over 15 years, modestly declining from 3.6 to 3.2 per million inhabitants. Significant regional differences were observed in timing, indications, and techniques. Proportion of primary versus secondary DC and surgery timing remained unchanged, though bifrontal DC decreased. Patients were young (median age 37), predominantly male (76%), severely injured (GCS M < 6), and 48% had unreactive pupils. Radiological improvement in mass effect post-DC (midline shift, basal cisterns) was significant ( p  < 0.001). Re-operation for haemorrhage occurred in 10%, complementary decompression, surgical-site infection, and subdural hygroma each occurred in ~ 5%. At 6 months, 60% had unfavourable outcomes and 11% were deceased. Higher age, lower GCS, comorbidities, impaired pupillary reactivity and obliterated basal cisterns independently predicted unfavourable outcome. Conclusions Landmark RCTs appear to have had limited influence on Swedish DC practice, which remains variable across centres. Real-world outcomes were more favourable than in recent RCTs and other acute brain injuries.

Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions. This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention. Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2–7.2 95 CI) had neurological decline, 73 (7.5% 5.9–9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5–7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1–0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305. RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.

Background Timing of surgical evacuation of mass lesions in traumatic brain injury (TBI) is crucial. However, due to geographical variations, transportation time to the nearest neurosurgical department may be long. To save time, general surgeons at a local hospital may perform the operation, despite more limited experience in neurosurgical techniques. This study aimed to determine whether patient outcomes differed between those who had undergone emergency neurosurgery at local hospitals by general surgeons vs. at university hospitals by neurosurgeons. Methods A nationwide observational study was performed using data from the Swedish Trauma Registry (SweTrau) between 2018 and 2022. A total of 565 TBI patients (local hospitals, n  = 21; university hospitals, n  = 544) who underwent intracranial hematoma evacuation within 8 h after arrival at the hospital were included. Data on demography, admission variables, traumatic injuries, and outcome (Glasgow Outcome Scale [GOS]) at discharge were evaluated. Favourable vs. unfavourable outcomes were defined as GOS scores of 4–5 vs. 1–3. Results Compared with those treated at university hospitals, patients treated with intracranial hematoma evacuation at local hospitals had lower median Glasgow Coma Scale (GCS) scores (8 vs. 12, p  < 0.001), higher rate of acute subdural hematomas (86% vs. 77%, p  < 0.001), and lower rate of contusions (14% vs. 53%, p  = 0.01). Being operated on at a local hospital was independently associated with higher mortality ( p  = 0.03) but with a similar rate of favourable outcome ( p  = 0.74) in multiple logistic regressions after adjustment for demographic and injury-related variables. Conclusions Although a slightly greater proportion of patients who underwent emergency neurosurgery at local hospitals died, there was no difference in the rate of favourable outcome. Thus, in patients with impending brain herniation, when time is of the essence, evacuation of traumatic intracranial bleeding by general surgeons at local hospitals remains a highly viable option.

Background Traumatic brain injury (TBI) is considered a major cause of death globally, resulting from trauma. Decompressive craniectomy (DC) may improve functional outcomes in patients with TBI and its associated complications. This study was designed to determine safety and efficacy of DC in improving clinical outcomes in TBI patients compared to standard therapy. Methods A systematic search was conducted across six electronic databases to identify relevant randomized controlled trials (RCTs) examining decompressive craniotomy (DC) and traumatic brain injury (TBI) from database inception until March 2021. The pooled risk ratio was estimated for categorical outcomes, while the pooled standardized mean difference with a 95% confidence interval was calculated for continuous outcomes. Statistical analysis software, including RevMan 5.4 and STATA version 17, was employed to perform this meta-analysis. The protocol for this study is registered with the OSF registry, ensuring transparency and reproducibility. Results A total of 656 studies were screened, and five RCTs involving 665 subjects (334 in the DC group and 331 in the control group) were included in this meta-analysis. Our meta-analysis revealed a non-significant trend towards a higher rate of favorable clinical outcomes in subjects who underwent DC compared to those in the medical treatment (MT) group (risk ratio (RR) 1.20, 95% confidence interval (CI) 0.70 to 2.08, P = 0.50). In contrast, the mortality rate was significantly lower in patients treated with DC compared to those receiving MT alone (RR 0.58, 95% CI 0.47 to 0.73, P < 0.001). Additionally, intracranial pressure (ICP) levels were significantly lower in subjects who underwent DC compared to those receiving MT alone (standardized mean difference (SMD): − 0.87, 95% CI − 1.58 to − 0.16, P = 0.02). Furthermore, there was a statistically significant reduction in the duration of stay in the DC group compared to the MT alone group (SMD: − 1.18, 95% CI − 1.49 to − 0.86, P < 0.001). Conclusion This study presents evidence suggesting that DC is linked to a lower mortality rate, decreased ICP, and shorter hospital stays among patients with moderate to severe TBI. However, it did not show a significant impact on improving favorable clinical outcomes.

Since the advent of replantation techniques, there has been uneven progress in terms of success—even considering whether success is defined as continued perfusion of the digit or long term functional outcomes. Early enthusiasm and success have not been maintained despite increasing familiarity with microsurgical techniques and greater understanding of how to optimize outcomes for the individual components of replantation such as tendon repair, nerve repair, and osteosynthesis. Practitioners participating in the care of patients undergoing replantation should be familiar with the history and current understanding of both the indications and contraindications for the procedure, post-operative rehabilitation, and factors contributing to functional outcomes. A review of the literature from the first publications on the topic demonstrates evolution in practice and understanding of which patients should be indicated for replantation. Indications can be considered in three broad categories: injury factors, patient factors, and care context factors. These factors intersect with one another and can inform the surgeon pre-operatively regarding the most likely outcome for a given patient. This insight is critical to discuss pre-operatively with the patient in order to make a shared decision about how to manage their injury.