Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement.

BACKGROUND: Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. METHODS: The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. RESULTS: The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. CONCLUSIONS: In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Detection of metabolic pattern following decompressive craniectomy in severe traumatic brain injury: A microdialysis study.

OBJECTIVE: The aim of the study was to detect mitochondrial dysfunction and ischaemia in severe traumatic brain injury and their relationship with outcome. METHODS: Forty-one patients with severe traumatic brain injury (TBI) who underwent decompressive craniectomy were prospectively monitored with intracerebral microdialysis catheters (MD). Variables related to energy metabolism were studied using microdialysis. RESULTS: Twentysix patients (63.4%) had a good outcome in terms of Glasgow outcome score (GOS) at 6 months while the rest (15 patients) had poor GOS at 6 months. Mitochondrial dysfunction was defined as Lactate Pyruvate ratio (LP ratio) > 25 and pyruvate <70 while ischaemia was defined as LP ratio > 25 and pyruvate >70. The poor outcome group showed significantly higher proportion of mitochondrial dysfunction 65.9% vs. 55.9% (p<0.001) and ischemia 13.9% vs. 7.2% (p<0.001) Conclusions: After decompressive craniectomy in severe TBI, patients with higher incidence of mitochondrial dysfunction and ischaemia were more likely to have poorer outcome with ischaemia having a more profound effect. ABBREVIATIONS: Traumatic brain injury (TBI), microdialysis (MD), lactate pyruvate ratio (LP ratio), Glasgow coma scale (GCS), Glasgow outcome scale (GOS), cerebral perfusion pressure (CPP), intracranial pressure (ICP), mitochondrial transition pore (MTP), non-contrast computed tomography (NCCT), traumatic axonal injury (TAI).

Evidence to support mitochondrial neuroprotection, in severe traumatic brain injury.

Traumatic brain injury (TBI) is still the leading cause of disability in young adults worldwide. The major mechanisms - diffuse axonal injury, cerebral contusion, ischemic neurological damage, and intracranial hematomas have all been shown to be associated with mitochondrial dysfunction in some form. Mitochondrial dysfunction in TBI patients is an active area of research, and attempts to manipulate neuronal/astrocytic metabolism to improve outcomes have been met with limited translational success. Previously, several preclinical and clinical studies on TBI induced mitochondrial dysfunction have focused on opening of the mitochondrial permeability transition pore (PTP), consequent neurodegeneration and attempts to mitigate this degeneration with cyclosporine A (CsA) or analogous drugs, and have been unsuccessful. Recent insights into normal mitochondrial dynamics and into diseases such as inherited mitochondrial neuropathies, sepsis and organ failure could provide novel opportunities to develop mitochondria-based neuroprotective treatments that could improve severe TBI outcomes. This review summarizes those aspects of mitochondrial dysfunction underlying TBI pathology with special attention to models of penetrating traumatic brain injury, an epidemic in modern American society.

Cross-Cultural Teachings from Cremation Practices: Atmaram for the Departed, Shiva Linga for the Living, and Odontoid Fracture for the Neurosurgeons!

Atmaram bone (C2 axis vertebra) is usually handed over to the family of the deceased on the next day after cremation during the ''Asthi sanchaya '' commemoration. ''Asthi visarajan'' involves the practice of immersing the bones and ashes of the deceased in the Holy Ganges river as per Hindu beliefs. Atmaram bone, which usually does not burn during cremation, is handed over to the family of the departed (asthi sanchaya) after cremation which is then immersed in the holy Ganges river ( asthi visarajan). Atma means soul, Ram means Lord and Atmaram combined means the one who is Lord of his own soul." Worshiping of Lord Shiva (while living) and Asthi sanchaya-Asthi visarajan (of the departed) are two religious venerations in Hinduism. Atmaram bone was handed over to me for immersion in the holy Ganges on November 6, 2020, after conducting the asthi sanchaya of my mother during the coronavirus disease 2019 (COVID-19) pandemic. Atmaram bone looked like a Shivalinga statue to most who looked at it, whereas it resembled the image of the axis vertebrae (C2 vertebra) to me when I saw it that sacred day. Atmaram bone, the Shivalinga, and the C2 axis vertebra are among the most precious and sacred objects that humans can handle as relatives, as devotees, and as neurosurgeons, respectively. Asclepius, possibly a skilled war surgeon/neurosurgeon, was worshipped at Asclepieia. Trephination surgery in neurosurgery and religion are intertwined historically. Though there is no published literature, neurosurgeons in various parts of the world do offer religious prayers prior to major neurosurgical operations. In line with the religious veneration of worshipping Shiva Ling or immersion of bones of the departed soul in the Holy Ganges river, we believe it is the sacred responsibility of the operating neurosurgeon to perform surgery in complex craniovertebral junction. As neurosurgeons, we cannot ignore the axis in the living, the odontoid fracture in the injured, and the Atmaram in the deceased.

Effects of liver ischemia-reperfusion injury on respiratory mechanics and driving pressure during orthotopic liver transplantation.

BACKGROUND: During orthotopic liver transplantation (OLT), liver graft ischemia-reperfusion injury (IRI) triggers a cytokine-mediated systemic inflammatory response, which impairs graft function and disrupts distal organ homeostasis. The objective of this prospective, observational trial was to assess the effects of IRI on lung and chest wall mechanics in the intraoperative period of patients undergoing OLT. METHODS: In 26 patients undergoing OLT, we measured elastance of the respiratory system (ERS), partitioned into lung (EL) and chest wall (ECW), hemodynamics, and fluid and blood product intake before laparotomy (T1), after portal/caval surgical clamp (T2), and immediately (T3) and, at 90 and 180 minutes post-reperfusion (T4 and T5, respectively). Interleukin-6 (IL-6), monocyte chemotactic protein-1 (MCP-1), IL-1ß and tumor necrosis factor-α plasma concentrations were assessed at T1, T4 and T5. RESULTS: EL significantly decreased from T1 to T2 (13.5±4.4 vs 9.7±4.8 cmH2O/L, P<0.05), remained stable at T3, while at T4 (12.3±4.4 cmH2O/L, P<0.05) was well above levels recorded at T2, reaching its highest value at T5 (15±3.9 cmH2O/L, P<0.05). Variations in ERS, EL, driving pressure (∆P) and trans-pulmonary pressure (∆PL) significantly correlated with changes in IL-6 and MCP-1 plasma concentrations, but not with changes in wedge pressure, fluid amounts, and red blood cells and platelets administered. No correlation was found between changes in cytokine concentrations and ECW. CONCLUSIONS: We found that EL, ECW, ∆P and ∆PL underwent significant variations during the OLT procedure. Further, we documented a significant association between the respiratory mechanics changes and the inflammatory response following liver graft reperfusion.

Monitoring the injured brain.

Traumatic brain injury can be defined as the most complex disease in the most complex organ. When an acute brain injury occurs, several pathophysiological cascades are triggered, leading to further exacerbation of the primary damage. A number of events potentially occurring after TBI can compromise the availability or utilization of energy substrates in the brain, ultimately leading to brain energy crisis. The frequent occurrence of secondary insults in the acute phase after TBI, such as intracranial hypertension, hypotension, hypoxia, hypercapnia, hyperthermia, seizures, can then increase cerebral damage, and adversely affect outcome. Neuromonitoring techniques provide clinicians and researchers with a mean to detect and reverse those processes that lead to this energy crisis, especially ischemic processes, and have become a critical component of modern neurocritical care. Which is the best way to monitoring the brain after an acute injury has been a matter of debate for decades. This review will discuss how monitoring the injured brain can reduce secondary brain damage and ameliorate outcome after acute brain injury.

The link between anesthesiology and neurology: a mindful cooperation to improve brain protection.

Preventing neurological injury is mandatory during the perioperative period of any kind of surgery and in the care of critically ill patients in the intensive care unit. During daily practice, both anesthesiologists and neurologists focus on brain protection as an integral part of systemic homeostasis maintenance. This article highlights the intriguing overlap between anesthesiology and neurology in clinical practice along with its potential implications for outcome. Moreover, it focuses on the importance of the complementary expertise of both specialists in maintaining cerebral homeostasis, with the aim of improving outcome. A review of available evidence on anesthesiology and neurology interplay in clinical practice along with its potential implications for outcome has been conducted. Clinical vigilance and the use of shared monitoring and diagnostic technology could allow early recognition and treatment of cerebral dysfunction occurring in the perioperative period or in the critical care setting, thus reducing morbidity and mortality. In order to improve patient safety and outcome, neurologists and anesthesiologists should more closely and successfully collaborate, using shared monitoring tools and integrating traditional areas of expertise. Daily activity, education, research and training programs in anesthesia and neurology could benefit from a stronger relationship with each other.

Italian COnsensus in Neuroradiological Anesthesia (ICONA).

Anesthetic management of patients undergoing endovascular procedures for treating intracranial aneurysms or cerebrovascular malformations must consider a number of specific challenges, in addition to those associated with anesthesia for other specialties. In addition to maintenance of physiological stability, manipulation of systemic and cerebral hemodynamic parameters may be required to treat any sudden unexpected catastrophic neurological events. A multidisciplinary group including neuro- and pediatric anesthesiologists, interventional neuroradiologists, neurosurgeons, and a clinical methodologist contributed to this document. This consensus working group from 21 Italian institutions identified open questions regarding the best practices for management of anesthesia during endovascular neuroradiological procedures for intracranial aneurysms and cerebrovascular malformations, and addressed these by formulating practical consensus statements. At the first meeting in November 2015, nine key areas were identified regarding choice of anesthetic, patient monitoring, hemodynamic targets, postoperative care, and the management of neuromuscular blockade, anticoagulant and/or antiplatelet therapy, and special considerations for pediatric patients. Nine subgroups were established and a medical librarian performed literature searches in the Cochrane and MEDLINE/PubMed databases for each group. Groups drafted literature summaries and provisional responses in the form of candidate consensus statements based on evidence, when possible, and clinical experience, when this was lacking. Final wording was agreed at a meeting in April 2016 and where possible evidence was graded using United States Preventive Services Task Force criteria. Consensus (defined as >90% agreement) was based on evidence, clinical experience, clinician preference, feasibility in the Italian healthcare system, and cost/benefit considerations.

Mitochondrial neuroprotection in traumatic brain injury: rationale and therapeutic strategies.

Traumatic brain injury (TBI) is still the worldwide, leading cause of mortality and morbidity in young adults. The prognosis of TBI patients is strongly affected by secondary brain damage including mitochondrial dysfunctions. In many basic and clinical studies, mitochondrial dysfunctions, including the opening of mitochondrial permeability transition (mPT) pore, and treatments including cyclosporine A (CsA) have been studied. These evidences suggest an important role for mitochondria as therapeutic targets for neuroprotection after TBI. This review summarizes the data about normal and pathological mitochondrial function after TBI, TBI pathobiology relating to mitochondrial dysfunction and therapeutic strategies including drug treatment. This review also mentioned about glucose, lactate, and pyruvate metabolisms in TBI, including the "astrocyte-neuron lactate shuttle (ANLS)" hypothesis. Mitochondrial pathophysiology in TBI is still unclear. Thus, the pharmacological treatment in TBI patient is still challenging. This review could help further understanding of this topic. Hopefully, this could help further development and innovation for drug therapies in TBI.

Microdialysis in the neurocritical care unit.

Effective monitoring is critical for neurologically compromised patients, and several techniques are available. One of these tools, cerebral microdialysis (MD), was designed to detect derangements in cerebral metabolism. Although this monitoring device began as a research instrument, favorable results and utility have broadened its clinical applications. Combined with other brain monitoring techniques, MD can be used to estimate cerebral vulnerability, to assess tissue outcome, and possibly to prevent secondary ischemic injury by guiding therapy. This article reviews the literature regarding the past, present, and future uses of MD along with its advantages and disadvantages in the intensive care unit setting.

Preconditioning for traumatic brain injury.

Traumatic brain injury (TBI) treatment is now focused on the prevention of primary injury and reduction of secondary injury. However, no single effective treatment is available as yet for the mitigation of traumatic brain damage in humans. Both chemical and environmental stresses applied before injury have been shown to induce consequent protection against post-TBI neuronal death. This concept termed "preconditioning" is achieved by exposure to different pre-injury stressors to achieve the induction of "tolerance" to the effect of the TBI. However, the precise mechanisms underlying this "tolerance" phenomenon are not fully understood in TBI, and therefore even less information is available about possible indications in clinical TBI patients. In this review, we will summarize TBI pathophysiology, and discuss existing animal studies demonstrating the efficacy of preconditioning in diffuse and focal type of TBI. We will also review other non-TBI preconditioning studies, including ischemic, environmental, and chemical preconditioning, which maybe relevant to TBI. To date, no clinical studies exist in this field, and we speculate on possible future clinical situations, in which pre-TBI preconditioning could be considered.