J Neurosurg Sci
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Decompressive craniectomy (DC) to control refractory intracranial hypertension in patients with traumatic brain injury (TBI), has been listed as possible but controversial therapeutic approach in the latest version of TBI management guidelines. This study aimed to perform a systematic review and meta-analysis on efficacy and safety of DC compared to standard care in TBI patients. ⋯ It seems that, in TBI patients with intracranial hypertension, the use of DC is associated with survival benefit when compared to medical therapy alone, but with no clear improvement of functional outcome. Yet no definite conclusion can be drawn due to limited quantity and considerable heterogeneity of available data.
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Traumatic brain injury (TBI) is a common cause of permanent disability for which clinical management remains suboptimal. Elevated intracranial pressure (ICP) is a common sequela following TBI leading to death and permanent disability if not properly managed. While clinicians often employ stepwise acute care algorithms to reduce ICP, a number of patients will fail medical management and may be considered for surgical decompression. ⋯ The current state of DC - including appropriate injury classification, surgical techniques, concurrent medical therapies, mortality and functional outcomes - is presented. We also report on the recent updates from large randomized controlled trials in severe TBI (Decompressive Craniectomy [DECRA] and Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP [RESCUEicp]), and recommendations for early DC to treat refractory ICP elevations in malignant middle cerebral artery syndrome. Limitations for DC, such as the equipoise between immediate reduction in ICP and clinically meaningful functional outcomes, are discussed in support of future investigations.
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Managing neurogenic shock following acute traumatic spinal cord injury (SCI) is challenging. Current guidelines target mean arterial pressure (MAP) above 85-90 mmHg to maintain cord perfusion and reduce ischemia/secondary injury. While early vasopressor utilization has been associated with improved outcomes, recent updates regarding indications of specific vasopressors for refinement of existing guidelines are needed. ⋯ Class III evidence has been augmented regarding vasopressor usage following acute SCI, however comparative benefits between vasopressors remain in need of elucidation due to small sample sizes and/or inadequate specificity to spine injury levels. Large prospective multicenter studies targeting age cohorts, and characterizing associated comorbidities and complication profiles, are of high priority in order to determine judicious use criteria of specific vasopressors for relevant subpopulations.
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Awake craniotomies (AC) could reduce neurological deficits compared with patients under general anesthesia, however, intraoperative seizure (IOS) is a major reason causing awake surgery failure. The purpose of the study was to give a comprehensive overview the published articles focused on seizure incidence in AC. ⋯ This systematic review and meta-analysis shows that AC is a safe technique with relatively low IOS occurrence. However, few RCTs were available, and the acquisition of further evidence through high-quality RCTs is highly recommended.
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Mechanical thrombectomy has become the stand of care for patients with large vessel occlusions, yet major improvements in thrombectomy speed, efficacy, and completeness can still be achieved. High rates of clot fragmentation and failure to remove the clot resulting in poor neurological outcomes suggest that in order to further advance the field of stroke intervention we must turn our attention towards understanding the science of clot. ⋯ Each of these features might logically predict superior thrombectomy outcomes with one device or another. This article aims to review the current literature on histopathological composition of acute ischemic stroke clots, with a particular focus on the correlation between clot composition and diagnostic imaging, stroke etiology and revascularization outcomes.