A review of external lumbar drainage for the management of intracranial hypertension in traumatic brain injury.

BACKGROUND: The Brain Trauma Foundation (BTF) published evidence-based guidelines with a detailed approach to the management of intracranial hypertension (ICH) in traumatic brain injury (TBI) patients. However, management with cerebrospinal fluid (CSF) drainage in TBI patients remains a controversial topic and is a recent addition to the 4th Edition of the BTF guidelines. External lumbar drainage (ELD) has been proposed for the management of patients with refractory ICH despite aggressive measures. ELD has been described in the literature with possible benefits in outcomes; still, many questions remain unanswered. METHODS: A systematic search on MEDLINE was conducted for articles that studied lumbar CSF drainage in adult TBI patients with ICH. RESULTS: Eleven studies met the inclusion criteria, which included 5 prospective and 6 retrospective studies. Several studies showed that CSF drainage via lumbar drain resulted in significant reduction of ICP compared to before ELD placement and had a low complication rate. However, the data reporting mortality and functional outcomes are varied across studies. CONCLUSION: The literature suggests that ELD may play a role in the management of refractory ICH in TBI patients when first and second-tier measures fail and may be a safe, effective, and minimally invasive method to significantly lower ICP. Additional research and standardized treatment protocols are necessary.

Diagnosis and Management of Traumatic Subarachnoid Hemorrhage: Protocol for a Scoping Review.

BACKGROUND: Globally, 69 million people suffer from traumatic brain injury (TBI) each year and TBI is the most common cause of subarachnoid hemorrhage (SAH). Traumatic SAH (TSAH) has been described as an adverse prognostic factor leading to progressive neurological deterioration and an increase in morbidity and mortality, but there are a limited number of studies which evaluate recent trends in the diagnostic and management of SAH in the context of trauma. OBJECTIVE: The objective of this scoping review was to understand the extent and type of evidence in relation to the diagnostic criteria and management of TSAH. METHODS: This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. A 3-step search strategy (an initial limited search in PubMed and Scopus databases; a main search of EMBASE, Web of Science, EBSCO, MEDLINE; and manual searches of reference lists of included articles) will be utilized. The search will be limited to studies with human participants and published in English, Spanish, and French between 2005 and 2020. This review will consider studies of adolescent and adult patients with SAH secondary to trauma. Study selection will be performed by 2 authors (DG and LF) in a 2-phase process; if any disagreement arises, a third author (AR) will be consulted. Data to be extracted from each study will include population, intervention, comparator and outcome measures, and a summary of findings. Citation screening, full-text review, risk of bias assessment, and extraction of study characteristics and outcomes will be carried out using a web-based software platform that streamlines the production of scoping reviews. RESULTS: Ethics approval is not required for this systematic review, as there will be no patient involvement. The search for this systematic review commenced in December 2020, and we expect to publish the findings in early 2021. The plan for dissemination is to publish review findings in a peer-reviewed journal and present findings at conferences that engage the most pertinent stakeholders. CONCLUSIONS: This scoping review will serve as an initial step in providing more evidence for health care professionals, economists, and policymakers so that they might devote more resources toward this significant problem affecting both health and economic outcomes worldwide. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/26709.

Consensus statement from the international consensus meeting on post-traumatic cranioplasty.

BACKGROUND: Due to the lack of high-quality evidence which has hindered the development of evidence-based guidelines, there is a need to provide general guidance on cranioplasty (CP) following traumatic brain injury (TBI), as well as identify areas of ongoing uncertainty via a consensus-based approach. METHODS: The international consensus meeting on post-traumatic CP was held during the International Conference on Recent Advances in Neurotraumatology (ICRAN), in Naples, Italy, in June 2018. This meeting was endorsed by the Neurotrauma Committee of the World Federation of Neurosurgical Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and several other neurotrauma organizations. Discussions and voting were organized around 5 pre-specified themes: (1) indications and technique, (2) materials, (3) timing, (4) hydrocephalus, and (5) paediatric CP. RESULTS: The participants discussed published evidence on each topic and proposed consensus statements, which were subject to ratification using anonymous real-time voting. Statements required an agreement threshold of more than 70% for inclusion in the final recommendations. CONCLUSIONS: This document is the first set of practical consensus-based clinical recommendations on post-traumatic CP, focusing on timing, materials, complications, and surgical procedures. Future research directions are also presented.

Systematic review of current randomised control trials in chronic subdural haematoma and proposal for an international collaborative approach.

BACKGROUND: Chronic subdural haematoma (CSDH) is a pathology that is frequently encountered by neurosurgeons. Nevertheless, there is a lack of guidelines based on solid evidence. There has been a recent and considerable increase in the interest on management and outcomes for CSDH. Therefore, we systematically reviewed all currently running randomised controlled trials (RCTs) in chronic subdural haematoma to understand the areas under investigation and plan future collaborative trials. METHODS: Clinical trials databases (Cochrane Controlled Register of Trials, WHO ICTRP and clinical trials.gov) were searched for trials relevant to chronic subdural haematoma. It was then established which trials were currently running and fulfilled robust research methodology for a RCT. RESULTS: There are 26 currently running RCTs in CSDH, with the most common topics covering application of steroids (7), surgical techniques (5) and tranexamic acid (5). Further to this, there are trials running on other pharmacological agents (4), middle meningeal artery (MMA) embolisation (2) and peri-operative management (3). CONCLUSIONS: Pharmacological agents are a particular focus of CSDH management currently, and a wealth of studies on steroids will hopefully lead to more harmonised, evidence-based practice regarding this in the near future. Surgical techniques and new procedures such as MMA embolisation are also important focuses for improving patient outcomes. There is an on-going need for future RCTs and evidence-based guidelines in CSDH, particularly including low- and middle-income countries, and it is hoped that the establishment of the iCORIC (International COllaborative Research Initiative on Chronic Subdural Haematoma) will help address this.

Trauma Ultrasound Training for Latin American Countries.

Objective: The Pan-American Trauma Society (PTS) developed a Trauma and Emergency Ultrasound Course (USET) in response to the requirement for trauma ultrasound training for low-and middle-income countries. The objective of this study was to evaluate the efficiency of this course. Method: Pre- and post-course tests were used. And interval estimation of proportions was calculated at 95% CI. Theoretical and practical pre- and post-course knowledge were assessed with the Wilcoxon Signed Rank test at 0.05 level of statistical significance. Result: Between 2005 and 2007, 114 students, including general surgeons, emergency medicine physicians, anesthesiologists, critical care physicians, and residents of these specialties, were trained in seven countries (Uruguay, Peru, Mexico, Venezuela, Aruba, Colombia, and Ecuador). The difference on complete knowledge ranked scores before and after the course was statistically significant (p<0.001). After the course, almost all participants (97.4%) demonstrated complete knowledge in final evaluation. Conclusion: The USET course is an effective approach for trauma ultrasound training. Specific training programs for trauma care providers that work in low-and middle-income countries are necessary and could be performed with low cost training programs.