Background Patients with severe traumatic brain injury (sTBI) are at high risk for developing venous thromboembolism (VTE). Nonetheless, pharmacologic VTE prophylaxis is often delayed out of concern ...for precipitating extension of intracranial hemorrhage (ICH). The purpose of this study was to compare the effectiveness of early vs late VTE prophylaxis in patients with sTBI, and to characterize the risk of subsequent ICH-related complication. Study Design Adults with isolated sTBI (head Abbreviated Injury Scale score ≥3 and total Glasgow Coma Scale score ≤8) who received VTE prophylaxis with low-molecular-weight or unfractionated heparin were derived from the American College of Surgeons Trauma Quality Improvement Program (2012 to 2014). Patients were divided into EP (<72 hours) or LP (≥72 hours) groups. Propensity score matching was used to minimize selection bias. The primary end point was VTE (pulmonary embolism or deep vein thrombosis). Secondary outcomes were defined as late neurosurgical intervention (≥72 hours) or death. Results We identified 3,634 patients with sTBI. Early prophylaxis was given in 43% of patients. Higher head injury severity, presence of ICH, and early neurosurgery were associated with late prophylaxis. Propensity score matching yielded a well-balanced cohort of 2,468 patients. Early prophylaxis was associated with lower rates of both pulmonary embolism (odds ratio = 0.48; 95% CI, 0.25–0.91) and deep vein thrombosis (odds ratio = 0.51; 95% CI, 0.36–0.72), but no increase in risk of late neurosurgical intervention or death. Conclusions In this observational study of patients with sTBI, early initiation of VTE prophylaxis was associated with decreased risk of pulmonary embolism and deep vein thrombosis, but no increase in risk of late neurosurgical intervention or death. Early prophylaxis may be safe and should be the goal for each patient in the context of appropriate risk stratification.
Abstract
Background
High-grade gliomas are the most common primary malignant brain tumor in adults having a median survival of only 13–16 months. This is despite the current standard of maximal safe ...surgical resection followed by fractionated radiotherapy and chemotherapy. Extending the tumor resection limit beyond the gadolinium (GAD)-enhancing margin (i.e., supra-marginal resection) could in principle provide an added survival benefit as it has been shown that > 80% of post-operative tumor recurrence is within a 2-cm region surrounding the original GAD-enhancing margin. However, this must be weighed against the risk of potential damage to functional brain tissue.
Methods
In this phase II pilot randomized control trial (RCT), we aim to assess the feasibility of “supra-marginal” resection extending 1 cm beyond the enhancing tumor in adults with radiographic evidence of GAD-enhancing intra-axial tumor consistent with high-grade glioma in a safe anatomical location and a Karnofsky Performance Score > 60. With six academic institutions with established neurosurgical oncology practices in participation, we aim to enroll 72 patients over 2 years. Primary outcomes include evaluating the feasibility of performing a large-scale trial with regard to recruitment, allocation, and outcome documentation as well as safety data. Secondary outcomes include determining if there is an increased survival benefit with supra-marginal resection and impact on quality of life (Modified Rankin Scale (mRS), EuroQol-5D (ED-5D), 30-day all-cause mortality).
Discussion
Recent studies have revealed survival advantages comparing supra-marginal resection to standard attempt at gross total resection (GTR) with no additional perioperative surgical risk; however, the current quality of evidence is low and under-powered. Therefore, there are no current practice guidelines, and the philosophy of surgical resection is guided by individual surgeon preferences on an individual patient basis. This creates additional uncertainty and is potentially detrimental to our patients. This clinical equipoise supports the need for an adequately powered RCT to determine whether a supra-marginal resection can have a positive impact on survival for patients with HGGs. Our pilot RCT will test the feasibility of comparing the standard gross total resection of GAD-enhancing tumors and supra-marginal resection to prepare for a larger definitive multicenter RCT.
Trial registration
ClinicalTrials.gov
, NCT04737577. Registered on February 4, 2021
Malignant peripheral nerve sheath tumors of the cerebellopontine angle are rare, especially even outside of the context of neurofibromatosis or malignant transformation of previously radiated ...vestibular schwannomas. This case report describes a case of a presumed vestibular schwannoma without previous radiation or history of neurofibromatosis presenting with progressive hearing loss, facial weakness, growth, and ultimately catastrophic hemorrhage requiring urgent surgery. Histopathology revealed an exceptionally rare malignant peripheral nerve sheath tumor with divergent mesenchymal (chondrosarcomatous) differentiation with few rigorously interrogated cases in the literature. In retrospect, facial weakness, growth, and early intratumoral hemorrhage were harbingers of atypical malignant pathology. We advocate for a heightened index of suspicion, shorter interval follow-up, and consideration of early surgery in such cases in hopes of preventing potentially catastrophic outcomes.
The surgical management of diffuse low-grade gliomas (DLGGs) has undergone a paradigm shift toward striving for maximal safe resection when feasible. While extensive observational data supports this ...transition, unbiased evidence in the form of high quality randomized-controlled trials (RCTs) is lacking. Furthermore, despite a high volume of molecular, genetic, and imaging data, the field of neuro-oncology lacks personalized care algorithms for individuals with DLGGs based on a robust foundation of evidence. In this manuscript, we (1) discuss the logistical and philosophical challenges hindering the development of surgical RCTs for DLGGs, (2) highlight the potential impact of well-designed international prospective observational registries, (3) discuss ways in which cutting-edge computational techniques can be harnessed to generate maximal insight from high volumes of multi-faceted data, and (4) outline a comprehensive plan of action that will enable a multi-disciplinary approach to future DLGG management, integrating advances in clinical medicine, basic molecular research and large-scale data mining.
There is an increasing number of trauma patients presenting on pre-injury antiplatelet (AP) agents attributable to an aging population and expanding cardio- or cerebrovascular indications for ...antithrombotic therapy. The effects of different AP regimens on outcomes after traumatic brain injury (TBI) have yet to be elucidated, despite the implications on patient/family counseling and the potential need for better reversal strategies. The goal of this systematic review and meta-analysis was to assess the impact of different pre-injury AP regimens on outcomes after TBI. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the OVID Medline, Embase, BIOSIS, Scopus, and Cochrane databases were searched from inception to February 2022 using a combination of terms pertaining to TBI and use of AP agents. Baseline demographics and study characteristics as well as outcome data pertaining to intracerebral hematoma (ICH) progression, need for neurosurgical intervention, hospital length of stay, mortality, and functional outcome were extracted. Pooled odds ratios (ORs) and mean differences comparing groups were calculated using random-effects models. Thirteen observational studies, totaling 1244 patients receiving single AP therapy with acetylsalicylic acid or clopidogrel, 413 patients on dual AP therapy, and 3027 non-AP users were included. No randomized controlled trials were identified. There were significant associations between dual AP use and ICH progression (OR, 2.81; 95% confidence interval CI, 1.19–6.61;
I
2
, 85%;
p
= 0.02) and need for neurosurgical intervention post-TBI (OR, 1.61; 95% CI, 1.15–2.28;
I
2
, 15%;
p
= 0.006) compared to non-users, but not between single AP therapy and non-users. There were no associations between AP use and hospital length of stay or mortality after trauma. Pre-injury dual AP use, but not single AP use, is associated with higher rates of ICH progression and neurosurgical intervention post-TBI. However, the overall quality of studies was low, and this association should be further investigated in larger studies.
There has been a paucity of information on the epidemiology of traumatic optic neuropathy (TON). This study documents epidemiology of TON over 2 decades in the largest level I adult trauma center in ...Canada.
Data on all the trauma patients admitted to Sunnybrook Health Sciences Centre from 1986 to 2007 were collected in a prospective database. The aggregate data on optic nerve injuries including demographic data, etiology, Injury Severity Score (ISS), and associated head and facial injuries were recorded. These were analyzed using univariate and multivariate techniques to summarize the association of different variables with TON.
During the study period, 0.4% of all trauma patients had TON. The respective demographics for TON group were as follows: male, 76%; median for age, 33.5 years; length of hospital stay, 14 days; ISS, 32; and case fatality, 14%. About two thirds of patients with TON had associated significant head injuries. Conversely, 2.3% of patients with head injury had TON. The relative incidence of TON per year has remained variable from 0% to 1.2%. Motorized vehicle accidents remained the main etiology of TON (63%), but fall had the highest relative frequency leading to TON. In univariate analysis, both ISS and significant head injury were associated with TON. In multivariate analysis, TON was associated with only nasoethmoid complex fractures and significant head injury.
These data provide useful information on the frequency and etiologies of TON. It also highlights the importance of studies on better diagnostic tools for TON.
The purpose of this note is to describe an obtuse-angled laminotomy of C7 during cervical decompression that aims to preserve cervicothoracic junction stability and potentially reduce pain. Cervical ...spondylotic myelopathy can result from degenerative cervical spinal disease including, herniated disk material, osteophytes, redundant ligamentum flavum, or ossification of the posterior longitudinal ligament. Surgical intervention for multilevel myelopathy aims to decompress the spinal cord and maintain stability of the cervical spine. Multilevel laminectomy is traditionally used when degenerative changes affect 3 or more levels and when there is primarily dorsal compressive disease. Traditional laminectomy can result in instability and kyphosis. The C7 lamina can be particularly vulnerable given the location at cervicothoracic junction. We describe an obtuse-angled laminotomy for the most caudal lamina in a planned decompression. This lamina is left attached to ligamentum nuchea, adjacent fascia, and paravertebral muscles. Only the base of spinous process and ventral portion of lamina's cortical and cancellous bone are removed in an obtuse angle through the opening. This variation is aimed to preserve as much of the cervical stability while still achieving the goal of decompression.
Duret hemorrhage is a rare phenomenon wherein rapid transtentorial herniation results in brainstem injury and hemorrhage. It is usually regarded as a poor prognostic factor representing irreversible ...and often catastrophic brain injury. The authors report an unusual case of Duret hemorrhage with spontaneous delayed neurological recovery postoperatively after surgical treatment of an acute subdural hematoma (SDH).
The authors present the case of a 65-year-old male who initially presented to the hospital with a large acute left-sided SDH causing 1.3 cm of midline shift. He was taken urgently for a craniotomy, with no significant intraoperative swelling or visible contusions. Postoperative imaging revealed an unexpected pontine hyperdensity concerning for a Duret hemorrhage. He initially had no neurological improvement; however, at 3 weeks postoperatively, he gradually recovered and was able to follow commands and was extubated. At 10 weeks after surgery, his Glasgow Coma Scale score improved to 15, with mild residual left hemiparesis.
This case challenges a classic dogma that Duret hemorrhage carries a universally poor outcome. In select cases, patients can make meaningful recoveries in a delayed fashion. The lack of intraoperative contusions and swelling may have contributed to this patient's recovery.
Abstract
High grade gliomas are the most common primary malignant brain tumor in adults having a median survival of only 13–16 months. This is despite the current standard of maximal safe surgical ...resection followed by fractionated radiotherapy and chemotherapy. Extending the tumor resection limit beyond the GAD-enhancing margin (i.e. supra-marginal resection) could in principle provide an added survival benefit as it has been shown that >80% of post-operative tumor recurrence is within a 2cm region surrounding the original GAD-enhancing margin. However, this must be weighed against the risk of potential damage to functional brain tissue. In this phase II pilot randomized control trial (RCT), we aim to assess the feasibility of “supra-marginal” resection extending 1cm beyond the enhancing tumor in adults with radiographic evidence of GAD-enhancing intra-axial tumour consistent with high grade glioma in a safe anatomical location and a Karnofsky Performance Score > 60. With six academic centres participating, we aim to enroll 72 patients over two years. Currently, four patients have already been enrolled in the first four months. Primary outcomes include evaluating the feasibility of performing a large-scale trial with regards to recruitment, allocation and outcome documentation as well as safety data. Secondary outcomes include determining if there is an increased survival benefit with supra-marginal resection and impact on quality of life. Our pilot RCT will test the feasibility of comparing standard gross total resection of GAD-enhancing tumour and supra-marginal resection to prepare for a larger definitive multicentre RCT.
PDF
