Background
Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as ...these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place.
Methods
Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting.
Results
We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms.
Conclusions
These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference.
Purpose Given its biological and anatomic features, autologous bone is the first choice for cranioplasty after bone decompression. When autologous bone is not available or must be replaced, surgeons ...can choose among various materials to create an alloplastic cranioplasty. The Italian Society for Neurosurgery promoted a prospective study conducted at 4 Italian neurosurgical units to compare different methods of cranioplasty and to assess the clinical results and incidence of complications. Materials and Methods Patients older than 14 years who underwent repositioning of autologous bone or 3-dimensional image-guided reconstruction with prostheses made of an alloplastic material (polyetheretherketone, polymethylmethacrylate, or hydroxyapatite) after cranial decompression were enrolled prospectively from January 2008 through December 2013. The collected data included the material used to produce the prosthesis, the type of cranioplasty (primary or secondary), and complications that required surgical removal of the prosthesis (eg, infection, bone resorption, and fracture of the cranioplasty). Results Ninety-six patients met the study criteria. Fifty cases were reconstructed with hydroxyapatite, 31 with bone, 13 with polymethylmethacrylate, and 2 with polyetheretherketone. Seven patients (7.3%) developed complications related to the cranioplastic implant that required reoperation. These complications included infection (4 cases), bone resorption (2 cases), and fracture of the cranioplastic prosthesis (1 case). Statistical analysis showed a higher rate of complications with the use of autologous bone versus alloplastic materials ( P = .03). Owing to the limited number of cases, no statistically meaningful complication was seen among the different alloplastic materials or when the cranioplastic implant was placed as secondary treatment. Conclusions These data and those of other reports suggest that cranioplasty conducted using alloplastic 3-dimensional reconstruction materials have a lower rate of complications than those conducted using autologous bone.
Management of glioblastoma multiforme (GBM) has been difficult using standard therapy (radiation with temozolomide chemotherapy). The ketogenic diet is used commonly to treat refractory epilepsy in ...children and, when administered in restricted amounts, can also target energy metabolism in brain tumors. We report the case of a 65-year-old woman who presented with progressive memory loss, chronic headaches, nausea, and a right hemisphere multi-centric tumor seen with magnetic resonance imaging (MRI). Following incomplete surgical resection, the patient was diagnosed with glioblastoma multiforme expressing hypermethylation of the MGMT gene promoter.
Prior to initiation of the standard therapy, the patient conducted water-only therapeutic fasting and a restricted 4:1 (fat: carbohydrate + protein) ketogenic diet that delivered about 600 kcal/day. The patient also received the restricted ketogenic diet concomitantly during the standard treatment period. The diet was supplemented with vitamins and minerals. Steroid medication (dexamethasone) was removed during the course of the treatment. The patient was followed using MRI and positron emission tomography with fluoro-deoxy-glucose (FDG-PET).
After two months treatment, the patient's body weight was reduced by about 20% and no discernable brain tumor tissue was detected using either FDG-PET or MRI imaging. Biomarker changes showed reduced levels of blood glucose and elevated levels of urinary ketones. MRI evidence of tumor recurrence was found 10 weeks after suspension of strict diet therapy.
This is the first report of confirmed GBM treated with standard therapy together with a restricted ketogenic diet. As rapid regression of GBM is rare in older patients following incomplete surgical resection and standard therapy alone, the response observed in this case could result in part from the action of the calorie restricted ketogenic diet. Further studies are needed to evaluate the efficacy of restricted ketogenic diets, administered alone or together with standard treatment, as a therapy for GBM and possibly other malignant brain tumors.
The use of augmented reality (AR) is growing in medical education, in particular, in radiology and surgery. AR has the potential to become a strategic component of neurosurgical training courses. In ...fact, over the years, there has been a progressive increase in the application of AR in the various fields of neurosurgery. In this study, the authors aim to define the diffusion of these augmented reality systems in recent years. This study describes future trends in augmented reality for neurosurgeons.
A systematic review of the literature was conducted to identify research published from December 1st, 2011 to November 30th, 2021. Electronic databases (PubMed, PubMed Central, and Scopus) were screened. The methodological quality of studies and extracted data were assessed for "augmented reality" and "neurosurgery". The data analysis focused on the geographical distribution, temporal evolution, and topic of augmented reality in neurosurgery.
A total of 198 studies have been included. The number of augmented reality applications in the neurosurgical field has increased during the last 10 years. The main topics on which it is mostly applied are spine surgery, neuronavigation, and education. The geographical distribution shows extensive use of augmented reality in the USA, Germany, China, and Canada. North America is the continent that uses augmented reality the most in the training and education of medical students, residents, and surgeons, besides giving the greatest research contribution in spine surgery, brain oncology, and surgical planning. AR is also extensively used in Asia for intraoperative navigation. Nevertheless, augmented reality is still far from reaching Africa and other countries with limited facilities, as no publications could be retrieved from our search.
The use of AR is significantly increased in the last 10 years. Nowadays it is mainly used in spine surgery and for neurosurgical education, especially in North America, Europe and China. A continuous growth, also in other aspects of the specialty, is expected in the next future.
BackgroundTraumatic brain injury (TBI) is a major global health issue, but low- and middle-income countries (LMICs) face the greatest burden. Significant differences in neurotrauma outcomes are ...recognised between LMICs and high-income countries. However, outcome data is not consistently nor reliably recorded in either setting, thus the true burden of TBI cannot be accurately quantified.ObjectiveTo explore the specific contextual challenges of, and possible solutions to improve, long-term follow-up following TBI in low-resource settings.MethodsA cross-sectional, pragmatic qualitative study, that considered knowledge subjective and reality multiple (i.e. situated within the naturalistic paradigm). Data collection utilised semi-structured interviews, by videoconference and asynchronous e-mail. Data were analysed using Braun and Clarke's six-stage Reflexive Thematic Analysis.Results18 neurosurgeons from 13 countries participated in this study, and data analysis gave rise to five themes: Clinical Context: What must we understand?; Perspectives and Definitions: What are we talking about?; Ownership and Beneficiaries: Why do we do it?; Lost to Follow-up: Who misses out and why?; Processes and Procedures: What do we do, or what might we do?ConclusionThe collection of long-term outcome data plays an imperative role in reducing the global burden of neurotrauma. Therefore, this was an exploratory study that examined the contextual challenges associated with long-term follow-up in LMICs. Where technology can contribute to improved neurotrauma surveillance and remote assessment, these must be implemented in a manner that improves patient outcomes, reduces clinical burden on physicians, and does not surpass the comprehension, capabilities, or financial means of the end user. Future research is recommended to investigate patient and family perspectives, the impact on clinical care teams, and the full economic implications of new technologies for follow-up.
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