PaCO2-management in the neuro-critical care of patients with subarachnoid hemorrhage.

The partial pressure of carbon dioxide (PaCO2) in the arterial blood is a strong vasomodulator affecting cerebral blood flow and the risk of cerebral edema and ischemia after acute brain injury. In turn, both complications are related to poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to analyze the effect of PaCO2 levels on the course and outcome of aSAH. All patients of a single institution treated for aSAH over 13.5 years were included (n = 633). Daily PaCO2 values from arterial blood gas measurements were recorded for up to 2 weeks after ictus. The study endpoints were: delayed cerebral ischemia (DCI), need for decompressive craniectomy due to increased intracranial pressure > 20 mmHg refractory to conservative treatment and poor outcome at 6-months follow-up (modified Rankin scale > 2). By correlations with the study endpoints, clinically relevant cutoffs for the 14-days mean values for the lowest and highest daily PaCO2 levels were defined by receiver operating characteristic curve analysis. Association with the study endpoints for the identifies subgroups was analyzed using multivariate analysis. The optimal range for PaCO2 values was identified between 30 and 38 mmHg. ASAH patients with poor initial condition (WFNS 4/5) were less likely to show PaCO2 values within the range of 30-38 mmHg (p < 0.001, OR = 0.44). In the multivariate analysis, PaCO2 values between 30 and 38 mmHg were associated with a lower risk for decompressive craniectomy (p = 0.042, aOR = 0.27), DCI occurrence (p = 0.035; aOR = 0.50), and poor patient outcome (p = 0.004; aOR = 0.42). The data from this study shows an independent positive association between low normal mean PaCO2 values during the acute phase of aSAH and patients' outcome. This effect might be attributed to the reduction of intracranial hypertension and alterations in the cerebral blood flow.

Prospective Study of Surgery for Traumatic Brain Injury in Addis Ababa, Ethiopia: Surgical Procedures, Complications, and Postoperative Outcomes.

BACKGROUND: Traumatic brain injury (TBI) is an important cause of trauma-related mortality and morbidity in Ethiopia. There are significant resource limitations along the entire continuum of care, and little is known about the neurosurgical activity and patient outcomes. METHODS: All surgically treated TBI patients at the 4 teaching hospitals in Addis Ababa, Ethiopia were prospectively registered from October 2012 to December 2016. Data registration included surgical procedures, complications, reoperations, discharge outcomes, and mortality. RESULTS: A total of 1087 patients were included. The most common procedures were elevation of depressed skull fractures (49.5%) and craniotomies (47.9%). Epidural hematoma was the most frequent indication for a craniotomy (74.7%). Most (77.7%) patients were operated within 24 hours of admission. The median hospital stay for depressed skull fracture operations or craniotomies was 4 days. Decompressive craniectomy was only done in 10 patients. Postoperative complications were seen in 17% of patients, and only 3% were reoperated. Cerebrospinal fluid leak was the most common complication (7.9%). The overall mortality was 8.2%. Diagnosis, admission Glasgow Coma Scale (GCS) score, surgical procedure, and complications were significant predictors of discharge GCS score (P < 0.01). Age, admission GCS score, and length of hospital stay were significantly associated with mortality (P ≤ 0.005). CONCLUSIONS: The injury panorama, surgical activity, and outcome are significantly influenced by patient selection due to deficits within both prehospital and hospital care. Still, the neurosurgical services benefit a large number of patients in the greater Addis region and are qualitatively comparable with reports from high-income countries.

A Safe Transitions Pathway for post-craniotomy neurological surgery patients: high-value care that bypasses the intensive care unit.

OBJECTIVE: High-value medical care is described as care that leads to excellent patient outcomes, high patient satisfaction, and efficient costs. Neurosurgical care in particular can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. The authors developed a "Safe Transitions Pathway" (STP) model in which select patients went to the postanesthesia care unit (PACU) and then the neuro-transitional care unit (NTCU) rather than being directly admitted to the neurosciences intensive care unit (ICU) following a craniotomy. They sought to evaluate the clinical and financial outcomes as well as the impact on the patient experience for patients who participated in the STP and bypassed the ICU level of care. METHODS: Patients were enrolled during the 2018 fiscal year (FY18; July 1, 2017, through June 30, 2018). The electronic medical record was reviewed for clinical information and the hospital cost accounting record was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impressions of the hospital stay and of the recovery pathway. RESULTS: No patients who proceeded to the NTCU postoperatively were upgraded to the ICU level of care postoperatively. There were no deaths in the STP group, and no patients required a return to the operating room during their hospitalization (95% CI 0%-3.9%). There was a trend toward fewer 30-day readmissions in the STP patients than in the standard pathway patients (1.2% [95% CI 0.0%-6.8%] vs 5.1% [95% CI 2.5%-9.1%], p = 0.058). The mean number of ICU days saved per case was 1.20. The average postprocedure length of stay was reduced by 0.25 days for STP patients. Actual FY18 direct cost savings from 94 patients who went through the STP was $422,128. CONCLUSIONS: Length of stay, direct cost per case, and ICU days were significantly less after the adoption of the STP, and ICU bed utilization was freed for acute admissions and transfers. There were no substantial complications or adverse patient outcomes in the STP group.

Predictors of 30-day hospital readmission after mechanical thrombectomy for acute ischemic stroke.

OBJECTIVE: The 30-day readmission rate is of increasing interest to hospital administrators and physicians, as it is used to evaluate hospital performance and is associated with increased healthcare expenditures. The estimated yearly cost to Medicare of readmissions is $17.4 billion. The Centers for Medicare and Medicaid Services therefore track unplanned 30-day readmissions and institute penalties against hospitals whose readmission rates exceed disease-specific national standards. One of the most important conditions with potential for improvement in cost-effective care is ischemic stroke, which affects 795,000 people in the United States and is a leading cause of death and disability. Recent widespread adoption of mechanical thrombectomy has revolutionized stroke care, requiring reassessment of readmission causes and costs in this population. METHODS: The authors retrospectively analyzed a prospectively maintained database of stroke patients and identified 561 patients who underwent mechanical thrombectomy between 2010 and 2019 at the authors' institution. Univariate and multivariate analyses were conducted to identify clinical variables and comorbidities related to 30-day readmissions in this patient population. RESULTS: Of the 561 patients, 85.6% (n = 480) survived their admission and were discharged from the hospital to home or rehabilitation, and 8.8% (n = 42/480) were readmitted within 30 days. The median time to readmission was 10.5 days (IQR 6.0-14.3). The most common reasons for readmission were infection (33.3%) and acute cardiac or cerebrovascular events (19% and 20%, respectively). Multivariate analysis showed that hypertension (p = 0.030; OR 2.72) and length of initial hospital stay (p = 0.040; OR 1.032) were significantly correlated with readmission within 30 days, while hemorrhagic conversion (grades 3 and 4) approached significance (p = 0.053; OR 2.23). Other factors, such as unfavorable outcome at discharge, history of coronary artery disease, and discharge destination, did not predict readmission. CONCLUSIONS: The study data demonstrate that hypertension, length of hospital stay, and hemorrhagic conversion were predictors of 30-day hospital readmission in stroke patients after mechanical thrombectomy. Infection was the most common cause of 30-day readmission, followed by cardiac and cerebrovascular diagnoses. These results therefore may serve to identify patients within the stroke population who require increased surveillance following discharge to reduce complications and unplanned readmissions.

Predictors of outcome in 1-month survivors of large middle cerebral artery infarcts treated by decompressive hemicraniectomy.

BACKGROUND: Decompressive hemicraniectomy (DH) increases survival without severe dependency in patients with large middle cerebral artery (LMCA) infarcts. The objective was to identify predictors of 1-year outcome after DH for LMCA infarct. METHODS: We conducted this study in consecutive patients who underwent DH for LMCA infarcts, in a tertiary stroke centre. Using multivariable logistic regression analyses, we evaluated predictors of (1) 30-day mortality and (2) poor outcome after 1 year (defined as a modified Rankin Scale score of 4-6) in 30-day survivors. RESULTS: Of 212 patients (133 men, 63%; median age 51 years), 35 (16.5%) died within 30 days. Independent predictors of mortality were infarct volume before DH (OR 1.10 per 10 mL increase, 95% CI 1.04 to 1.16), delay between symptom onset and DH (OR 0.41, 95% CI 0.23 to 0.73 per 12 hours increase) and midline shift after DH (OR 2.59, 95% CI 1.09 to 6.14). The optimal infarct volume cut-off to predict death was 210 mL or more. Among the 177 survivors, 77 (43.5%) had a poor outcome at 1 year. Independent predictors of poor outcome were age (OR 1.08 per 1 year increase, 95% CI 1.03 to 1.12) and weekly alcohol consumption of 300 g or more (OR 5.30, 95% CI 2.20 to 12.76), but not infarct volume. CONCLUSION: In patients with LMCA infarcts treated by DH, stroke characteristics (infarct volume before DH, midline shift after DH and early DH) predict 30-day mortality, while patients' characteristics (age and excessive alcohol intake) predict 1-year outcome survivors.

Statistical Cerebrovascular Reactivity Signal Properties after Secondary Decompressive Craniectomy in Traumatic Brain Injury: A CENTER-TBI Pilot Analysis.

Decompressive craniectomy (DC) in traumatic brain injury (TBI) has been suggested to influence cerebrovascular reactivity. We aimed to determine if the statistical properties of vascular reactivity metrics and slow-wave relationships were impacted after DC, as such information would allow us to comment on whether vascular reactivity monitoring remains reliable after craniectomy. Using the CENTER-TBI High Resolution Intensive Care Unit (ICU) Sub-Study cohort, we selected those secondary DC patients with high-frequency physiological data for both at least 24 h pre-DC, and more than 48 h post-DC. Data for all physiology measures were separated into the 24 h pre-DC, the first 48 h post-DC, and beyond 48 h post-DC. We produced slow-wave data sheets for intracranial pressure (ICP) and mean arterial pressure (MAP) per patient. We also derived a Pressure Reactivity Index (PRx) as a continuous cerebrovascular reactivity metric updated every minute. The time-series behavior of the PRx was modeled for each time period per patient. Finally, the relationship between ICP and MAP during these three time periods was assessed using time-series vector autoregressive integrative moving average (VARIMA) models, impulse response function (IRF) plots, and Granger causality testing. Ten patients were included in this study. Mean PRx and proportion of time above PRx thresholds were not affected by craniectomy. Similarly, PRx time-series structure was not affected by DC, when assessed in each individual patient. This was confirmed with Granger causality testing, and VARIMA IRF plotting for the MAP/ICP slow-wave relationship. PRx metrics and statistical time-series behavior appear not to be substantially influenced by DC. Similarly, there is little change in the relationship between slow waves of ICP and MAP before and after DC. This may suggest that cerebrovascular reactivity monitoring in the setting of DC may still provide valuable information regarding autoregulation.

Complications in cranioplasty after decompressive craniectomy: timing of the intervention.

OBJECTIVE: To prevent complications following decompressive craniectomy (DC), such as sinking skin flap syndrome, studies suggested early cranioplasty (CP). However, several groups reported higher complication rates in early CP. We studied the clinical characteristics associated with complications in patients undergoing CP, with special emphasis on timing. METHODS: A single-center observational cohort study was performed, including all patients undergoing CP from 2006 to 2018, to identify predictors of complications. RESULTS: 145 patients underwent CP: complications occurred in 33 (23%): 18 (12%) epi/subdural hemorrhage, 10 (7%) bone flap infection, 4 (3%) hygroma requiring drainage, and 1 (1%) post-CP hydrocephalus. On univariate analysis, acute subdural hematoma as etiology of DC, symptomatic cerebrospinal fluid (CSF) flow disturbance (hydrocephalus) prior to CP, and CP within three months after DC were associated with higher complication rates. On multivariate analysis, only acute subdural hematoma as etiology of DC (OR 7.5; 95% CI 1.9-29.5) and symptomatic CSF flow disturbance prior to CP (OR 2.9; 95% CI 1.1-7.9) were associated with higher complication rates. CP performed within three months after DC was not (OR 1.4; 95% CI 0.5-3.9). Pre-CP symptomatic CSF flow disturbance was the only variable associated with the occurrence of epi/subdural hemorrhage. (OR 3.8; 95% CI 1.6-9.0) CONCLUSION: Cranioplasty has high complication rates, 23% in our cohort. Contrary to recent systematic reviews, early CP was associated with more complications (41%), explained by the higher incidence of pre-CP CSF flow disturbance and acute subdural hematoma as etiology of DC. CP in such patients should therefore be performed with highest caution.

Decompressive hemicraniectomy in the management of subcortical spontaneous intracerebral hemorrhage.

BACKGROUND: The benefit of decompressive hemicraniectomy in patients with malignant acute ischemic stroke is well established, however its role in supratentorial intracerebral hemorrhages is unclear and evolving. Prior studies combined cortical and subcortical hemorrhages in their analysis despite their different natural history. Subcortical hematoma is associated with worse outcomes due to mechanical compression of subcortical structures. We describe outcomes of a matched comparison of patients with spontaneous subcortical hemorrhage managed with hemicraniectomy versus medical management alone. METHODS: Using our "Get-with-the-guideline stroke" database, patients with spontaneous subcortical hematoma managed with hemicraniectomy were identified. Using age, gender, and hematoma volume (categorized as 0-30, 30-60, >60ml), patients managed with hemicraniectomy were matched with medical management alone. Outcomes included hospital length of stay, discharge disposition, and Glasgow outcome score. RESULTS: Eight patients with subcortical hematoma managed with hemicraniectomy were matched with 22 medically managed patients. Other than use of antithrombotics, clinical characteristics did not differ between groups. On comparing outcomes, hospital length of stay in the hemicraniectomy group (26.5 vs 12.5 days p = 0.006) was significantly longer. Discharge disposition did not differ between groups (75% vs 36.4% p = 0.101). Despite a higher frequency of Glasgow outcome score ≥ 3 at 90 days amongst hemicraniectomy cases, there was no significant difference between groups (71.3% vs 54.5% p = 0.535). CONCLUSION: Hemicraniectomy for subcortical hematoma was associated with a prolonged hospital stay. Despite improving survival and favorable discharge disposition, there was no statistically significant difference between groups. Further studies on the benefit of hemicraniectomy in subcortical hematoma are needed.

Risk factors for decompressive craniectomy after endovascular treatment in acute ischemic stroke.

Endovascular treatment (EVT) is safe and effective for acute ischemic stroke (AIS) caused by large artery occlusion in the anterior circulation. However, some patients require decompressive craniectomy (DC), despite having undergone a timely EVT. This study aimed to evaluate the risk factors for subsequent DC after EVT. This retrospective cohort study comprised 138 patients who received EVT between April 2015 and June 2019 at our center. The need for subsequent DC was defined as cerebral edema or/and hemorrhagic transformation caused by large ischemic infarction, with a ≥ 5-mm midline shift and clinical deterioration after EVT. The relationship between risk factors and DC after EVT was assessed via univariate and multivariable logistic regression. Thirty (21.7%) patients required DC. These patients tended to have atrial fibrillation (P = 0.037), sedation (P = 0.049), mechanical ventilation (P = 0.008), poorer collateral circulation (P = 0.003), a higher baseline National Institutes of Health Stroke Scale (NIHSS) score (P < 0.001), heavier thrombus burden (P < 0.001), a lower baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (P < 0.001), and unsuccessful recanalization (P < 0.001). In the multivariate analysis, higher baseline NIHSS score [odds ratio (OR), 1.17; 95% confidence interval (CI), 1.03-1.32], heavier thrombus burden [OR, 1.35; 95% CI, 1.02-1.79], baseline ASPECTS ≤ 8 [OR, 7.41; 95% CI, 2.43-22.66], and unsuccessful recanalization [OR, 7.49; 95% CI, 2.13-26.36] were independent risk factors for DC after EVT. DC remains an essential treatment for some AIS patients after EVT, especially those with higher baseline NIHSS scores, heavier thrombus burden, baseline ASPECTS ≤ 8, and unsuccessful recanalization.

Reoperations after surgery for acute subdural hematoma: reasons, risk factors, and effects.

PURPOSE: To analyze the reasons and patient-related and injury-related risk factors for reoperation after surgery for acute subdural hematoma (SDH) and the effects of reoperation on treatment outcome. METHODS: Among adult patients operated on for acute SDH between 2013 and 2017, patients reoperated within 14 days after the primary surgery were identified. In all patients, parameters were identified that related to the patient (age, anticoagulation, antiplatelet, and antiepileptic treatment, and alcohol intoxication), trauma (Glasgow Coma Score, SDH thickness, midline shift, midline shift /hematoma thickness rate, other surgical lesion, primary surgery-trephination, craniotomy, or decompressive craniotomy), and Glasgow Outcome Score (GOS). The reasons for reoperation and intervals between primary surgery and reoperation were studied. RESULTS: Of 86 investigated patients, 24 patients were reoperated (27.9%), with a median interval of 2 days between primary surgery and reoperation. No significant differences in patients and injury-related factors were found between reoperated and non-reoperated patients. The rate of primary craniectomies was higher in non-reoperated patients (P = 0.066). The main indications for reoperation were recurrent /significant residual SDH (10 patients), contralateral SDH (5 patients), and expansive intracerebral hematoma or contusion (5 patients). The final median GOS was 3 in non-reoperated and 1.5 in reoperated patients, with good outcomes in 41.2% of non-reoperated and 16.7% of reoperated patients. CONCLUSIONS: Reoperation after acute SDH surgery is associated with a significantly worse prognosis. Recurrent /significant residual SDH and contralateral SDH are the most frequently found reasons for reoperation. None of the analyzed parameters were significant reoperation predictors.

Isolated Traumatic Brain Injury in the Very Old.

BACKGROUND: Older age is an independent predictor of worse outcome from traumatic brain injury (TBI). No clear guidelines exist for the management of TBI in elderly patients. OBJECTIVES: To describe the outcomes of elderly patients presenting with TBI and intracranial bleeding (ICB), comparing a very elderly population (≥ 80 years of age) to a younger one (70-79). METHODS: Retrospective analysis of the outcomes of elderly patients presenting with TBI with ICB admitted to a level I trauma center. RESULTS: The authors analyzed 100 consecutive patients aged 70-79 and 100 patients aged 80 and older. In-hospital mortality rates were 9% and 21% for groups 70-79 and ≥ 80 years old, respectively (P = 0.017). Patients 70-79 years old showed a 12-month survival rate of 73% and a median survival of 47 months. In patients ≥ 80 years old, 12-month survival was 63% and median survival was 27 months (P = NS). In patients presenting with a Glasgow Coma Scale score of ≥ 8, the in-hospital mortality rates were 41% (n=5/12) and 100% (n=8/8). Among patients ≥ 80 years old undergoing emergent surgical decompression, in-hospital mortality was 66% (n=12/18). Survivors presented with a severe drop in their functional score. Survival was dismal in patients ≥ 80 years old who were treated conservatively despite recommended operative guidelines. CONCLUSIONS: There is a lack of reliable means to evaluate the outcome in patients with poor functional status at baseline. The negative prognostic impact of severe TBI is profound, regardless of treatment choices.

Characteristics of traumatic brain injury during Operation Enduring Freedom-Afghanistan: a retrospective case series.

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality, especially among members of the armed services. Injuries sustained in the battlefield are subject to different mechanisms than those sustained in civilian life, particularly blast and high-velocity injury. Due to the unique nature of these injuries and the challenges associated with battlefield medicine, surgical interventions play a key role in acute management of TBI. However, the burden of chronic disease posed by TBI is poorly understood and difficult to investigate, especially in the military setting. The authors report the case logs of a United States Navy neurosurgeon, detailing the acute management and outcomes of 156 patients sustaining TBI between November 2010 and May 2011 during the war in Afghanistan. By demographics, more than half of the patients treated were local nationals. By mechanism of injury, blunt trauma (40.4%) and explosive injury (37.2%) were the most common contributors to TBI. Decompressive craniectomies (24.0%) and clot evacuations (14.7%) were the procedures most commonly performed. Nearly one-quarter of patients were transferred to receive further care, yet only 3 patients were referred for rehabilitative services. Furthermore, the data suggest that patients sustaining comorbid injuries in addition to TBI may be predisposed to worse outcomes. Improvements in documentation of military patients may improve knowledge of TBI and further identify potential variables or treatments that may affect prognosis. The increased survivability from TBI also highlights the need for additional research expenditure in the field of neurorehabilitation specifically.

Retrospective analysis of decompressive craniectomy performed in pediatric patients with subdural hematoma.

BACKGROUND: The impact of decompressive craniectomy (DC) on the overall outcome of pediatric acute subdural hematoma patients has not been fully determined to date. In this paper, we aimed to investigate the role of decompressive craniectomy performed to treat traumatic subdural hematoma in patients from the pediatric age group. METHODS: We described our experience with DC in pediatric acute subdural hematoma patients and analyzed the outcomes. RESULTS: Eleven (7 unilateral and 4 bilateral) DCs were performed. The patients' ages ranged from 8 months to 15 years. The mean GCS score at admission was 7.8. All patients underwent DC with duraplasty within 2 hours of injury. All the patients were admitted to the intensive care unit for 10 days postoperatively. The mean hospital stay was 22 days and the mean follow-up period was 3.7 years. CONCLUSION: Early DC for pediatric subdural hematoma patients, independent of their initial GCS, was recommended. Larger studies are needed to define the indications, surgical techniques, and timing of DC in the pediatric population.

Recent Nationwide Impact of Mechanical Thrombectomy on Decompressive Hemicraniectomy for Acute Ischemic Stroke.

Background and Purpose- The treatment of patients with acute ischemic stroke has been revolutionized by endovascular mechanical thrombectomy (MT), leading to dramatically improved outcomes. Here, we analyzed the impact of recent changes in stroke management on nationwide trends in patient characteristics, treatment modalities, and outcomes. Methods- The National Inpatient Sample was analyzed using International Classification of Diseases, Ninth and Tenth Editions, Clinical Modification codes to identify adult stroke patients with anterior-circulation, large-vessel occlusion in the pre- (2012-2014) and the post-MT trial period (2015-2016). Univariate and multivariable predictors of decompressive hemicraniectomy (DHC) were ascertained in patients developing malignant cerebral edema. Results- The nationwide query identified 519 320 adult stroke patients with annually increasing volume (92 320 to 129 340), stroke severity, and treatment at urban teaching centers. DHC was performed in 9.5% of patients developing malignant cerebral edema (n=33 530) and was associated with a high rate of discharge to long-term nursing care (65%) and mortality (23%). Over time, the rate of MT (3.4% to 9.8%) increased whereas the rate of DHC for malignant cerebral edema declined from 11.4% to 4.8% (P<0.001). In a binary logistic regression model controlling for potential confounders (eg, age, severity of illness), MT patients were 43% less likely to require DHC (odds ratio, 0.7; 95% CI, 0.6-0.9). Conclusions- Nationwide trends indicated that successful reperfusion of penumbra with MT in stroke patients leads to a declining indication for DHC whereas stroke volume increases over time.

Inadequate Decompressive Craniectomy Following a Wartime Traumatic Brain Injury - An Illustrative Case of Why Size Matters.

Traumatic brain injury has been called the "signature injury" of the wars in Iraq and Afghanistan, and the management of severe and penetrating brain injury has evolved considerably based on the experiences of military neurosurgeons. Current guidelines recommend that decompressive hemicraniectomy be performed with large, frontotemporoparietal bone flaps, but practice patterns vary markedly. The following case is illustrative of potential clinical courses, complications, and efforts to salvage inadequately-sized decompressive craniectomies performed for combat-related severe and penetrating brain injury. The authors follow this with a review of the current literature pertaining to decompressive craniectomy, and finally provide their recommendations for some of the technical nuances of performing decompressive hemicraniectomy after severe or penetrating brain injury.

Impact of randomized controlled trials on neurosurgical practice in decompressive craniectomy for ischemic stroke.

Randomized controlled trials (RCTs) are gold standard for comparing treatment modalities. Recently, RCTs transformed ischemic stroke care by first proving benefit of decompressive craniectomy (DC) and later of interventional mechanical thrombectomy. Aim of this study was to explore the impact of RCTs on neurosurgical practice. RCTs investigating DC and thrombectomy were identified. Annual numbers of DCs for ischemic stroke between 2000 and 2017 were determined and correlated with publication dates of RCTs. The initial RCTs demonstrating efficacy of DC were published in 2007, followed by an increase in DC numbers between 2008 and 2009. The first RCTs on mechanical thrombectomy were published in 2014 and 2015, with a decline in DCs observed between 2015 and 2016. There is a close temporal relationship between publication of these RCTs and changes in neurosurgical practice. Dynamics of annual DCs appear to correlate with the publication of RCTs. Significantly positive results of surgical and interventional RCTs were translated into clinical practice with a latency of 1 year, as reflected by shifts in annual DC numbers.

Predictors of decompressive hemicraniectomy in malignant middle cerebral artery stroke.

Identification of factors in malignant middle cerebral artery (MMCA) stroke patients that may be useful in selecting patients for DHC. This study was a retrospective multicenter study of patients referred for DHC based on the criteria of the randomized control trials of DHC in MMCA stroke. Demographic, clinical, and radiology data were analyzed. Patients who underwent DHC were compared to those who survived without surgery. Two hundred three patients with MMCA strokes were identified: 137 underwent DHC, 47 survived without DHC, and 19 refused surgery and died. Multivariate analysis identified the following factors determining DHC in MMCA stroke: age < 55 years (OR 8.5, 95% CI 3.3-22.1, P < 0.001), MCA with involvement of additional vascular territories (anterior cerebral artery, posterior cerebral artery (OR 4.8, 95% CI 1.5-14.9, P = 0.007), septum pellucidum displacement ≥ 7.5 mm (OR 4.8, 95% CI 1.9-11.7, P = 0.001), diabetes (OR 3.7, 95% CI 1.3-10.6, P = 0.012), infarct growth rate (IGR) ml/h (OR 1.11, 95% CI 1.02-1.2, P = 0.015), and temporal lobe involvement (OR 2.5, 95% CI 1.01-6.1, P = 0.048). The internal validation of the multivariate logistic regression model using bootstrapping analysis showed marginal bias. Among patients with MMCA infarctions, an increased possibility of DHC is associated with younger age, MCA with additional infarction, septum pellucidum deviation of > 7.5 mm, diabetes, IGR, and temporal lobe involvement. The presence of these risk factors identifies those MMCA stroke patients who may require DHC. Bootstrapping analysis indicated the model is good enough to predict the outcome in general population.

Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study.

BACKGROUND: Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe. METHODS: A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP). RESULTS: The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions. CONCLUSION: Despite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care.

Decompressive hemicraniectomy after malignant middle cerebral artery infarction: does hospital of origin matter?

Decompressive hemicraniectomy (DHC) has been shown to reduce mortality in malignant middle cerebral artery (MCA) infarction. Our primary objective was to compare 1-year mortality between patients receiving DHC for malignant MCA infarction at our institution based on hospital of origin. We retrospectively reviewed the medical records of all patients treated for malignant MCA infarction with DHC at our institution over a 3-year period. One-year mortality rates and time to surgery were comparable regardless of whether the patient first attended the tertiary referral centre or a peripheral centre.

Critical thresholds for intracranial pressure vary over time in non-craniectomised traumatic brain injury patients.

BACKGROUND: Intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-guided therapy is central to neurocritical care for traumatic brain injury (TBI) patients. We sought to identify time-dependent critical thresholds for mortality and unfavourable outcome for ICP and CPP in non-craniectomised TBI patients. METHODS: This is a retrospective cohort study of 355 patients with moderate-to-severe TBI who received ICP monitoring and were managed without decompressive craniectomy in a tertiary hospital neurocritical care unit. Patients were grouped in 2 × 2 tables according to survival/death or favourable/unfavourable outcomes at 6 months and serial thresholds of mean ICP and CPP, using increments of 0.1 and 0.5 mmHg respectively. Sequential chi-square analysis was performed, and the thresholds yielding the highest chi-square test statistic were taken as having the best discriminative value for outcome. This process was repeated over monitoring periods of 1, 3, 5 and 7 days and for each day of recording to establish time-dependent thresholds. The same analysis was performed for age and sex subgroups. RESULTS: Global ICP thresholds were 21.3 and 20.5 mmHg for mortality and unfavourable outcome respectively (p < 0.001). After the first day of ICP monitoring, ICP thresholds fell to between 15 and 20 mmHg and remained significant (p < 0.05). Significant time-dependent CPP thresholds for mortality or unfavourable outcome were often not identified, and no identifiable trends were produced. CONCLUSION: Critical ICP thresholds in non-craniectomised TBI patients vary with time and fall below established ICP targets after the first day of monitoring.