Embolization of the middle meningeal artery for the prevention of chronic subdural hematoma recurrence in high-risk patients: a randomized controlled trial-the EMPROTECT study protocol.

BACKGROUND: Middle meningeal artery (MMA) embolization has been proposed as a treatment of chronic subdural hematoma (CSDH). The benefit of the procedure has yet to be demonstrated in a randomized controlled trial. We aim to assess the efficacy of MMA embolization in reducing the risk of CSDH recurrence 6 months after burr-hole surgery compared with standard medical treatment in patients at high risk of postoperative recurrence. METHODS: The EMPROTECT trial is a multicenter open label randomized controlled trial (RCT) involving 12 French centers. Adult patients (≥18 years) operated for CSDH recurrence or for a first episode with a predefined recurrence risk factor are randomized 1:1 to receive either MMA embolization within 7 days of the burr-hole surgery (experimental group) or standard medical care (control group). The number of patients to be included is 342. RESULTS: The primary outcome is the rate of CSDH recurrence at 6 months. Secondary outcomes include the rate of repeated surgery for a homolateral CSDH recurrence during the 6-month follow-up period, the rate of disability and dependency at 1 and 6 months, defined by a modified Rankin Scale (mRS) score ≥4, mortality at 1 and 6 months, total cumulative duration of hospital stay during the 6-month follow-up period, directly or indirectly related to the CSDH and embolization procedure-related complication rates. CONCLUSIONS: The EMPROTECT trial is the first RCT evaluating the benefit of MMA embolization as a surgical adjunct for the prevention of CSDH recurrence. If positive, this trial will have a significant impact on patient care. TRIAL REGISTRATION NUMBER: NCT04372147.

Ethical Issues Regarding Neurosurgical Management of Penetrating Brain Injury in the French Armed Forces.

Combat penetrating brain injury (PBI) differs significantly from PBI in civilian environments. Differences include technical factors such as the weapons involved, strained resource environments, and limited medical materials and human resources available. Ethical issues regarding the management of PBI in military settings may occur. This case study examines the case of a 20-year-old member of the French Armed Forces that suffered a penetrating brain injury in a combat situation. The four-quadrant method along with the four principles of medical ethics (respect for autonomy, beneficence, nonmaleficence, and justice) was used to analyze this case and to apply ethics to the practice of military medicine. Nowadays, we possess the medical and surgical resources as well as the aeromedical evacuation capability to save the life of a soldier with a penetrating craniocerebral wound. Nonetheless, the functional outcome of this type of wound places military doctors in an ethical dilemma. The line of conduct and clinical protocol established by the French Medical Health Service is to manage all PBIs when the patient's life can be saved and to provide all available financial and social support for the rehabilitation of patients and their family.

French Military Neurosurgery: At Home and Abroad.

The origins of military neurosurgery are closely linked to those of neurosurgery in France and more particularly in Paris. The history of the field starts with its origins by 2 men, Thierry de Martel and Clovis Vincent. The first note about the creation of military neurosurgery was in 1942, when Marcel David was reassigned from the Sainte Anne Hospital to practice at the Val-de-Grâce Military Hospital. David trained the first military neurosurgeon. The field of military neurosurgery was subsequently developed at the Val-de-Grâce Military Hospital, at Sainte Anne Military Teaching Hospital in Toulon in 1990 and then at Percy Military Teaching Hospital in 1996. Over 29 military neurosurgeons were trained in these institutions. Since 2000, French military neurosurgeons have been deployed from France in the Mobile Neurosurgical Unit. This Mobile Neurosurgical Unit represents 12% of all medical evacuation of casualties categorized as the high dependency level. Neurosurgeons were able to adapt to asymmetrical wars, such as in the Afghanistan campaign where they were deployed in the Role 3 medical treatment facility, and more recently in sub-Saharan conflicts where they were deployed in forward surgical roles. To manage the increasing craniocerebral war casualties in the forward surgical team, the French Military Health Service Academy established a training course referred to as the "Advanced Course for Deployment Surgery" providing neurosurgical damage control skills to general surgeons. Finally, military neurosurgery is reinventing itself to adapt to future conflicts through the enhancement of surgical practices via the addition of head, face, and neck surgeons.

Acute neurosurgical management of traumatic brain injury and spinal cord injury in French armed forces during deployment.

This article aims to describe the French concept regarding combat casualty neurosurgical care from the theater of operations to a homeland hospital. French military neurosurgeons are not routinely deployed to all combat zones. As a consequence, general surgeons initially treat neurosurgical wounds. The principle of this medical support is based on damage control. It is aimed at controlling intracranial hypertension spikes when neuromonitoring is lacking in resource-limited settings. Neurosurgical damage control permits a medevac that is as safe as can be expected from a conflict zone to a homeland medical treatment facility. French military neurosurgeons can occasionally be deployed within an airborne team to treat a military casualty or to complete a neurosurgical procedure performed by a general surgeon in theaters of operation. All surgeons regardless of their specialty must know neurosurgical damage control. General surgeons must undergo the required training in order for them to perform this neurosurgical technique.

Management of War-Related Ballistic Craniocerebral Injuries in a French Role 3 Hospital During the Afghan Campaign.

INTRODUCTION: France deployed to Afghanistan from 2001 to 2014 within the International Security and Assistance Force. A French role 3 hospital was built in 2009 in the vicinity of Kabul International Airport (KaIA). The objectives of this study were to describe the epidemiology, management, and outcome of war-related craniocerebral injuries during the Afghan campaign in a French role 3 hospital. METHODS: From March 1, 2010 to September 30, 2012, we conducted a retrospective descriptive study in Kabul, Afghanistan. All patients presenting with a ballistic craniocerebral injury to the KaIA role 3 hospital were included. RESULTS: We analyzed 48 records. Mean age was 21.9 years (1-46 years) with a 37:11 (male:female) sex ratio and a majority Afghan population (n = 41). Civilians represented 64.6% (n = 31) of casualties. On the battlefield, mean Glasgow Coma Scale score was 9.4 [3-15]. On arrival at the KaIA field hospital, 20 of the 48 patients were hemodynamically unstable. All patients underwent a full-body computed tomography scan. The majority of our casualties had associated injuries. Neurosurgery was indicated for 42 (87.5%) patients. The surgery consisted of wound debridement plane by plane associated with decompressive craniectomy (n = 11), debridement craniectomy (n = 19), and craniotomy (n = 12). A total of 32.4% wounded died at the point of injury, 8.4% at the emergency department, and 16.9% after surgery. CONCLUSIONS: War casualties with ballistic head injuries were predominantly multitraumatized patients with hemodynamic compromise requiring neurosurgical damage control management and multidisciplinary care. The neurosurgeon has thus an essential role to play.

Potential Pitfalls of Reporting and Bias in Observational Studies With Propensity Score Analysis Assessing a Surgical Procedure: A Methodological Systematic Review.

OBJECTIVE: To describe the evolution of the use and reporting of propensity score (PS) analysis in observational studies assessing a surgical procedure. BACKGROUND: Assessing surgery in randomized controlled trials raises several challenges. Observational studies with PS analysis are a robust alternative for comparative effectiveness research. METHODS: In this methodological systematic review, we identified all PubMed reports of observational studies with PS analysis that evaluated a surgical procedure and described the evolution of their use over time. Then, we selected a sample of articles published from August 2013 to July 2014 and systematically appraised the quality of reporting and potential bias of the PS analysis used. RESULTS: We selected 652 reports of observational studies with PS analysis. The publications increased over time, from 1 report in 1987 to 198 in 2013. Among the 129 reports assessed, 20% (n = 24) did not detail the covariates included in the PS and 77% (n = 100) did not report a justification for including these covariates in the PS. The rate of missing data for potential covariates was reported in 9% of articles. When a crossover by conversion was possible, only 14% of reports (n = 12) mentioned this issue. For matched analysis, 10% of articles reported all 4 key elements that allow for reproducibility of a PS-matched analysis (matching ratio, method to choose the nearest neighbors, replacement and method for statistical analysis). CONCLUSIONS: Observational studies with PS analysis in surgery are increasing in frequency, but specific methodological issues and weaknesses in reporting exist.

Military neurosurgery in operation: experience in the French role-3 medical treatment facility of Kabul.

BACKGROUND: In 2009, during the war in Afghanistan, the increasing number of head injuries led to the deployment of a military neurosurgeon at the Kabul International Airport (KaIA) medical treatment facility, in March 2010. The main goal of this study was to depict the neurosurgical activity in this centre and to analyse its different aspects. METHOD: A retrospective study of all the neurosurgical patients treated in KaIA from March 2010 to June 2013. RESULTS: Three hundred and seventy-three interventions performed by the neurosurgeon deployed were reported for 373 surgeries, in 335 patients, representing 10.6 % of the overall surgical activity of the centre. Among the 69 interventions performed on soldiers, 57 surgeries were undertaken in emergency (82.6 %), while 12 were elective procedures (17.4 %). On the other hand, 289 surgeries were performed in civilian Afghans, with 126 emergency procedures in (43.6 %), against 163 elective interventions (56.4 %). Among the 44.5 % (n = 149) of the traumatic casualties, cerebral lesions represented 28.7 % (n = 96) and spinal lesions 12.4 % (n = 42). Ninety patients had multiple injuries. Additionally, patients without trauma accounted for 55.5 % (n = 186) of the overall population. Thus, 49 % (n = 164) were operated on for non-traumatic lesion of the spine. These were mostly civilian Afghans treated under medical aid to the population (90.2 %, n = 148/164). CONCLUSIONS: The military neurosurgeon had two roles in KaIA: both to support the armed forces and to manage medical aid to the civilian population. This study gives food for thought on the neurosurgical needs in modern warfare, and on the skills required for the military neurosurgeon.