Neuro damage control: current concept and civilian applications.

Damage control (DC) initially referred to abbreviated (<1 h) surgical procedures to control abdominal hemorrhage in severe trauma patients, to avoid the 'bloody vicious circle' of hypothermia-coagulopathy-acidosis-hypocalcemia. Progressively, the concept was extended to pre-hospital and peri-operative surgical and non-surgical trauma care. The DC strategy can be applied either in a single severe trauma patient at risk of progression toward the bloody vicious circle or in case of limited or overwhelmed health resources (deprived environment, mass casualties, etc.). DC strategies in neurological casualties have improved over the last decade in military neurosurgeons, but remain poorly codified in civilian settings. In this comprehensive review, we summarize the current concept of neuro-DC, which includes surgical and medical care for neurological injuries as part of a DC strategy. Neuro-DC basically consists in: (i) preventing secondary brain injury; (ii) controlling intracranial bleeding; (iii) controlling intracranial pressure; (iv) limiting contamination of compound wounds; and (v) achieving secondary anatomical restoration.

ABO blood type and functional neurological outcome in patients with severe traumatic brain injury.

BACKGROUND: The ABO blood system has been involved in the pathogenesis of several diseases, including coagulopathy and bleeding complications. In trauma patients, blood type A has been associated with acute respiratory distress syndrome, and recently, blood type O has been associated with all-cause mortality. The purpose of this study was to assess the association between ABO blood types and long-term functional outcomes in critically ill patients with severe traumatic brain injury (TBI). METHODS: We conducted a single-center, retrospective, observational study including all patients admitted to the intensive care unit with severe TBI (defined as a Glasgow Coma Scale score of ≤8) between January 2007 and December 2018. Patient characteristics and outcomes were extracted from a prospective registry of all intubated patients admitted to the intensive care unit for TBI. ABO blood types were retrospectively retrieved from patient medical records. The association between ABO blood type (A, B, AB, and O) and unfavorable functional outcome (defined by a Glasgow Outcome Scale score between 1 and 3) 6 months after injury was assessed in univariate and multivariate analysis. RESULTS: A total of 333 patients meeting the inclusion criteria were included. There were 151 type O (46%), 131 type A (39%), 37 type B (11%), and 12 type AB patients (4%). No significant differences in baseline demographic, clinical, or biological characteristics were observed between blood types. The prevalence of unfavorable outcome was significantly different between the four groups. After adjustment for confounders, blood type O was significantly associated with unfavorable outcome at 6 months (odds ratio, 1.97; confidence interval [1.03-3.80]; p = 0.042). The prevalence of coagulopathy or progressive hemorrhagic injury was not statistically different between blood types ( p = 0.575 and p = 0.813, respectively). CONCLUSION: Blood type O appears to be associated with unfavorable long-term functional outcome in critically ill patients with severe TBI. Further studies are needed to detail the mechanism underlying this relationship. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Neurosurgical Consultation Referral from the Forces: Regarding 328 Patients Referred to the Department of Neurosurgery, Sainte Anne Military Hospital, France.

INTRODUCTION: There are little data regarding elective referral to the military specialist, especially considering common pathologies such as spinal diseases, which, in the French forces, involve military neurosurgeons. An overview of the management of the military patient referred to neurosurgery consultation, especially considering spinal diseases that both constitute an operational healthissue in the forces and appear of special interest. The objective was to describe the reasons, demographics, and care pathways, addressed to the neurosurgeon. MATERIALS AND METHODS: This retrospective, single-center study focused on all military patients referred for neurosurgery consultation at Sainte Anne Military Hospital in Toulon. Extracted data included demographic characteristics, army, unit, military specialty, the reason for referral, the diagnosis by the neurosurgeon, treatment, and outcome. RESULTS: From January 2018 to December 2019, 352 patients were referred for neurosurgical consultation by the unit general practitioner. Spinal disease (n = 297, 91%) was the most frequent reason. Lumbar degenerative disk disease accounted for 20% of consultations, regardless of the patient's unit or specialty. Most of the patients seen in consultation received nonsurgical management (n = 271, 82.6%). These patients mainly presented with cervical or lumbar degenerative disk disease (n = 99, 36.5%) or cervical or lumbar herniated discs (n = 57, 21.0%). Ninety-eight patients (29.9%) were referred exclusively for medical fitness assessment. Few patients experienced full resolution of their presenting complaint after management (n = 9, 2.8%). CONCLUSIONS: This descriptive study demonstrates the predominance of degenerative spinal diseases in military patients referred to neurosurgery. It reflects the importance of the medical and military competence required to maintain operational capability upstream and downstream of war traumatology. The description of the care pathways invites us to define more proactive multidisciplinary pathways for the management of these diseases in the armed forces.

Natural history of spinal cord metastasis from brain glioblastomas.

BACKGROUND AND OBJECTIVES: Spinal cord metastasis arising from an intracranial glioblastoma is a rare and late event during the natural course of the disease. These pathological entities remain poorly characterized. This study aimed to identify and investigate the timeline, clinical and imaging findings, and prognostic factors of spinal cord metastasis from a glioblastoma. METHODS: Consecutive histopathological cases of spinal cord metastasis from glioblastomas in adults entered in the French nationwide database between January 2004 and 2016 were screened. RESULTS: Overall, 14 adult patients with a brain glioblastoma (median age 55.2 years) and harboring a spinal cord metastasis were included. The median overall survival as 16.0 months (range, 9.8-22.2). The median spinal cord Metastasis Free Survival (time interval between the glioblastoma diagnosis and the spinal cord metastasis diagnosis) was 13.6 months (range, 0.0-27.9). The occurrence of a spinal cord metastasis diagnosis greatly impacted neurological status: 57.2% of patients were not ambulatory, which contributed to dramatically decreased Karnofsky Performance Status (KPS) scores (12/14, 85.7% with a KPS score ≤ 70). The median overall survival following spinal cord metastasis was 3.3 months (range, 1.3-5.3). Patients with a cerebral ventricle effraction during the initial brain surgery had a shorter spinal cord Metastasis Free Survival (6.6 vs 18.3 months, p = 0.023). Out of the 14 patients, eleven (78.6%) had a brain IDH-wildtype glioblastoma. CONCLUSIONS: Spinal cord metastasis from a brain IDH-wildtype glioblastoma has a poor prognosis. Spinal MRI can be proposed during the follow-up of glioblastoma patients especially those who have benefited from cerebral surgical resection with opening of the cerebral ventricles.

Natural Course and Prognosis of Primary Spinal Glioblastoma: A Nationwide Study.

BACKGROUND AND OBJECTIVES: Primary spinal glioblastoma (PsGBM) is extremely rare. The dramatic neurologic deterioration and unresectability of PsGBM makes it a particularly disabling malignant neoplasm. Because it is a rare and heterogeneous disease, the assessment of prognostic factors remains limited. METHODS: PsGBMs were identified from the French Brain Tumor Database and the Club de Neuro-Oncologie of the Société Française de Neurochirurgie retrospectively. Inclusion criteria were age 18 years or older at diagnosis, spinal location, histopathologic diagnosis of newly glioblastoma according to the 2016 World Health Organization classification, and surgical management between 2004 and 2016. Diagnosis was confirmed by a centralized neuropathologic review. The primary outcome was overall survival (OS). Therapeutic interventions and neurologic outcomes were also collected. RESULTS: Thirty-three patients with a histopathologically confirmed PsGBM (median age 50.9 years) were included (27 centers). The median OS was 13.1 months (range 2.5-23.7), and the median progression-free survival was 5.9 months (range 1.6-10.2). In multivariable analyses using Cox model, Eastern Cooperative Oncology Group (ECOG) performance status at 0-1 was the only independent predictor of longer OS (hazard ratio [HR] 0.13, 95% CI 0.02-0.801; p = 0.02), whereas a Karnofsky performance status (KPS) score <60 (HR 2.89, 95% CI 1.05-7.92; p = 0.03) and a cervical anatomical location (HR 4.14, 95% CI 1.32-12.98; p = 0.01) were independent predictors of shorter OS. The ambulatory status (Frankel D-E) (HR 0.38, 95% CI 0.07-1.985; p = 0.250) was not an independent prognostic factor, while the concomitant standard radiochemotherapy with temozolomide (Stupp protocol) (HR 0.35, 95% CI 0.118-1.05; p = 0.06) was at the limit of significance. DISCUSSION: Preoperative ECOG performance status, KPS score, and the location are independent predictors of OS of PsGBMs in adults. Further analyses are required to capture the survival benefit of concomitant standard radiochemotherapy with temozolomide.

Hydrocephalus despite extra ventricular drainage in adults: a new description of multiloculated hydrocephalus.

Multiloculated hydrocephalus constitutes a challenging pathology due to intracerebral haemorrhage or ventriculitis leading to iterative shunt revision frequently described in paediatric neurosurgery, but poorly reported in adults. Nevertheless, this potential complication of intraventricular haemorrhage, already drained in emergency, should be considered with special interest, as ideal management of cerebrospinal drainage remains debated in such situation. We thus report herein the case of intraventricular haemorrhage in an adult complicated of multiloculated hydrocephalus, as an illustrative plea for endoscopic surgery.

Application of a Near-infrared Spectroscope by an Extreme Forward Medical Team for the Triage of Casualties With Traumatic Brain Injury.

BACKGROUND: During deployment of military medical teams similarly to prehospital practice, without immediate computed tomography scan access, identifying patients requiring neuro-specific care to manage pragmatic triage proves crucial. We assessed the contribution of this portable near-infrared spectroscope (NIRS) handheld device, Infrascanner Model 2000 (InfraScan Inc.; Philadelphia, PA), to screen patients suspected to require specific neurosurgical care. MATERIALS AND METHODS: This single-center retrospective analysis was based on the data from the medical records of the traumatic brain injured patients. We analyzed all the patients strictly over 18 years old presenting a clinical history of traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) < 15. RESULTS: Thirty-seven medical records of patients admitted for TBI met the inclusion criteria for our analysis. The median GCS was 9 [3-14]. Eight patients (21.6%) underwent neurosurgery and 25 (67.6%) required intensive care unit (ICU) admission, after initial assessment and resuscitation. The NIRS was the most sensible to detect intracranial hematoma (n = 21), intracranial hematoma leading to surgery (n = 8), and intracranial hematoma leading to admission in ICU (n = 25). Its negative predictive value was 100% regarding hematomas leading to surgery. False-positive results were encountered in 10 cases (27.0%). Excluding cases harboring confounding extracranial hematomas, parietal area was still the most represented (n = 3). CONCLUSION: The NIRS was relevant to detect hematoma leading to prompt surgery in our study. The lack of specificity in a nonselected cohort of patients underlines the need to associate simple clinical feature such as neurological deficit and NIRS results to perform rational triage.

Multi-component prime-boost Chlamydia trachomatis vaccination regimes induce antibody and T cell responses and accelerate clearance of infection in a non-human primate model.

It is of international priority to develop a vaccine against sexually transmitted Chlamydia trachomatis infections to combat the continued global spread of the infection. The optimal immunization strategy still remains to be fully elucidated. The aim of this study was to evaluate immunization strategies in a nonhuman primate (NHP) model. Cynomolgus macaques (Macaqua fascicularis) were immunized following different multi-component prime-boost immunization-schedules and subsequently challenged with C. trachomatis SvD in the lower genital tract. The immunization antigens included the recombinant protein antigen CTH522 adjuvanted with CAF01 or aluminium hydroxide, MOMP DNA antigen and MOMP vector antigens (HuAd5 MOMP and MVA MOMP). All antigen constructs were highly immunogenic raising significant systemic C. trachomatis-specific IgG responses. In particularly the CTH522 protein vaccinated groups raised a fast and strong pecificsIgG in serum. The mapping of specific B cell epitopes within the MOMP showed that all vaccinated groups, recognized epitopes near or within the variable domains (VD) of MOMP, with a consistent VD4 response in all animals. Furthermore, serum from all vaccinated groups were able to in vitro neutralize both SvD, SvE and SvF. Antibody responses were reflected on the vaginal and ocular mucosa, which showed detectable levels of IgG. Vaccines also induced C. trachomatis-specific cell mediated responses, as shown by in vitro stimulation and intracellular cytokine staining of peripheral blood mononuclear cells (PBMCs). In general, the protein (CTH522) vaccinated groups established a multifunctional CD4 T cell response, whereas the DNA and Vector vaccinated groups also established a CD8 T cells response. Following vaginal challenge with C. trachomatis SvD, several of the vaccinated groups showed accelerated clearance of the infection, but especially the DNA group, boosted with CAF01 adjuvanted CTH522 to achieve a balanced CD4/CD8 T cell response combined with an IgG response, showed accelerated clearance of the infection.

Emergency Cranial Surgeries Without the Support of a Neurosurgeon: Experience of the French Military Surgeons.

INTRODUCTION: Unlike orthopedic or visceral surgeons, French military neurosurgeons are not permanently deployed on the conflict zone. Thus, craniocerebral war casualties are often managed by general surgeons in the mobile field surgical team. The objective of the study was to provide the feedback of French military surgeons who operated on craniocerebral injuries during their deployment in a role 2 surgical hospital without a neurosurgeon. MATERIALS AND METHODS: A cross-sectional survey was conducted by phone in March 2020, involving every military surgeon currently working in the French Military Training Hospitals, with an experience of cranial surgery without the support of a neurosurgeon during deployment. We strived to obtain contextual, clinical, radiological, and surgical data. RESULTS: A total of 33 cranial procedures involving 64 surgeons were reported from 1993 to 2018. A preoperative CT scan was not available in 18 patients (55%). Half of the procedures consisted in debridement of craniocerebral wounds (52%, n = 17), followed by decompressive craniectomies (30%, n = 10), craniotomy with hematoma evacuation (15%, n = 5), and finally one (3%) surgery with exploratory burr holes were performed. The 30-day survival rate was 52% (n = 17) and 50% (n = 10/20) among the patients who sustained severe traumatic brain injury. CONCLUSIONS: This survey demonstrates the feasibility and the plus-value of a neurosurgical damage control procedure performed on the field by a surgeon nonspecialized in cranial surgery. The stereotyped neurosurgical techniques used by the in-theater surgeon were learned during a specific predeployment training course. However, the use of a live telemedicine neurosurgical support seems indispensable and could benefit the general surgeon in strained resources setting.

Severe Trauma Patients Requiring Undelayable Combined Cranial and Extra-Cranial Surgery: A Proof-of-Concept Monocentric Study.

INTRODUCTION: To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome. MATERIALS AND METHODS: We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting. RESULTS: The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%). CONCLUSION: Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.

Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept.

Objectives: Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH). Materials and Methods: A scoping review was conducted on Medline database from inception to September 2021. Results: The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D). Conclusion: This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.

Neurosurgery for intracranial meningioma in patients aged more than 80 years: benefits and rationale.

BACKGROUND: Elderly patients with symptomatic benign intracranial tumours such as meningioma pose particular problems in decision making. We report on the outcome, morbidity and mortality in patients aged over 80 years after undergoing cranial surgery for meningiomas. METHODS: In this retrospective study, 37 patients aged more than 80 years underwent surgery at our neurosurgery department. The Karnofsky Performance Scale (KPS) was used to assess functional status. The American Society of Anesthesiologists (ASA) classification system, the Geriatric Scoring System, the Clinical-Radiological Grading System and the Sex, Karnofsky, ASA, Location and Edema score were used to define clinical status and tumour characteristics. The Charlson Comorbidity Index and Clavien-Dindo classification scores reflected therapeutic morbidity. RESULTS: Preoperative KPS scores were generally higher than 60 (n = 32). Of the 37 patients, 24 (64.8%) were in ASA class I or II, and 27 (73.0%) had one or more comorbidities. The median length of follow-up was 80.0 months (range: 1-96 months). The 1-year mortality rate was 2.7% (n = 1). Tumour control was achieved in 33 patients. At discharge, KPS scores were improved in 21 patients (with an average gain of +18.1 ± 8.7), stable in 10 patients and poorer in 6 patients. KPS scores improved or were stable in patients with shorter lengths of hospital stay (15.5 ± 17.9 days vs 51.4 ± 25.4 days; p < 0.01), those with Clavien-Dindo scores lower than 2 (p < 0.01) and those with less favourable preoperative KPS scores (69.4 ± 10.9 vs 82.0 ± 11.0; p = 0.04). CONCLUSION: Historically, surgery for intracranial meningiomas in patients aged >80 years has been feasible; this series demonstrated decreasing rates of postoperative mortality. Functional benefit should be the main goal of surgery. Perioperative morbidity should be better assessed and predicted because it significantly influences functional outcomes.

Brain metastases in endometrial cancer: A systematic review of the surgical prognostic factors.

CONTEXT: Although endometrial cancer is the fourth most common malignancy in women, dissemination to the brain is an exceptional event in the course of the disease. The aim of this review is to determine the important surgical prognostic factors for patients with endometrial cancer metastatic to the brain. MATERIALS AND METHODS: Report of two cases. Medline database was used to conduct a systematic literature review from inception to December 2020 looking for English-language articles focused on brain metastases from endometrial cancer. RESULTS: The research yielded 108 articles, among which 23 articles were retained for a total of 87 patients. Mean age was 60 years-old ±11 at the time of diagnosis of endometrial cancer, and most of the tumors were aggressive (grade 3) with an advanced-stage disease (FIGO III-IV). At the time of diagnosis of cerebral disease, a single brain metastasis (p < 0.0001) and no extra-cerebral metastatic site (p = 0.0011) were significant good prognostic factors for the median overall survival. Surgical excision of brain metastasis followed by radiotherapy provided the longest median overall survival compared to radiotherapy and/or chemotherapy, and surgery alone (respectively 32, 5.4 and 4.8 months, p < 0.0001). An age of 60-year-old or less was not associated with a better prognosis. CONCLUSION: This review confirms that surgical excision followed by radiotherapy is a reliable option in patients with a single brain metastasis from endometrial cancer and no extra-cerebral metastatic site. This work could help to adapt the Graded Prognostic Assessment for brain metastases in endometrial cancer.

Ability of Fibrin Monomers to Predict Progressive Hemorrhagic Injury in Patients with Severe Traumatic Brain Injury.

BACKGROUND: Progressive hemorrhagic injury (PHI) is common in patients with severe traumatic brain injury (TBI) and is associated with poor outcomes. TBI-associated coagulopathy is frequent and has been described as risk factor for PHI. This coagulopathy is a dynamic process involving hypercoagulable and hypocoagulable states either one after the other either concomitant. Fibrin monomers (FMs) are a direct marker of thrombin action and thus reflect coagulation activation. This study sought to determine the ability of FM to predict PHI after severe TBI. METHODS: We conducted a prospective, observational study including all severe TBI patients admitted in the trauma center. Between September 2011 and September 2016, we enrolled patients with severe TBI into the derivation cohort. Between October 2016 and December 2018, we recruited the validation cohort on the same basis. Study protocol included FM measurements and standard coagulation test at admission and two computed tomography (CT) scans (upon arrival and at least 6 h thereafter). A PHI was defined by an increment in size of initial lesion (25% or more) or the development of a new hemorrhage in the follow-up CT scan. Multivariate logistic regression analysis was applied to identify predictors of PHI. RESULTS: Overall, 106 patients were included in the derivation cohort. Fifty-four (50.9%) experienced PHI. FM values were higher in these patients (151 [136.8-151] vs. 120.5 [53.3-151], p < 0.0001). The ROC curve demonstrated that FM had a fair accuracy to predict the occurrence of PHI with an area under curve of 0.7 (95% CI [0.6-0.79]). The best threshold was determined at 131.7 µg/ml. In the validation cohort of 54 patients, this threshold had a negative predictive value of 94% (95% CI [71-100]) and a positive predictive value of 49% (95% CI [32-66]). The multivariate logistic regression analysis identified 2 parameters associated with PHI: FM ≥ 131.7 (OR 6.8; 95% CI [2.8-18.1]) and Marshall category (OR 1.7; 95% CI [1.3-2.2]). Coagulopathy was not associated with PHI (OR 1.3; 95% CI [0.5-3.0]). The proportion of patients with an unfavorable functional neurologic outcome at 6-months follow-up was higher in patients with positive FM: 59 (62.1%) versus 16 (29.1%), p < 0.0001. CONCLUSIONS: FM levels at admission had a fair accuracy to predict PHI in patients with severe TBI. FM values ≥ 131.7 µg/ml are independently associated with the occurrence of PHI.