World Neurosurg
-
Randomized Controlled Trial
"Cisternostomy Vs Decompressive Craniectomy for The Management of Traumatic Brain Injury: A Randomized Controlled Trial".
The goal of treatment of traumatic brain injury (TBI) is to avoid secondary brain injury. Decompressive craniectomy has been shown to reduce intracranial pressure (ICP), but it actually provides an outlet for brain tissue to expand without reducing edema. Basal cisternostomy is an emerging microsurgical technique to manage cerebral edema in TBI. Cerebrospinal fluid is released from basal cisterns, which reduces cerebral edema. We compared outcomes of cisternostomy with decompressive craniectomy in a randomized controlled trial and studied the effectiveness of cisternostomy in decreasing cerebral edema. ⋯ Cisternostomy was effective in reducing ICP in patients with TBI. Good Glasgow Outcome Scale scores and low rates of complications were found in the postoperative period after cisternostomy. Age, presenting Glasgow Coma Scale score, Marshall score, other major injuries, and time from trauma to surgery had a significant prognostic impact on outcome in management of TBI.
-
Meta Analysis
Post Traumatic Amnesia: A Systematic Review and Meta-Analysis. Proposal for a New Severity Classification.
Posttraumatic amnesia (PTA) duration is used to predict outcome after traumatic brain injury (TBI): however, no meta-analysis exists. ⋯ PTA duration was reliable in predicting outcome when <7 days, and especially when >42 days but was often unreliable between 7 and 42 days duration.
-
Hypertonic saline (HTS) is a widely used adjunct in the treatment of traumatic brain injury (TBI). However, there is significant variability in practice patterns. Toward the goal of optimality and standardization in the use of HTS in TBI, we performed a comprehensive review of clinical protocols reported in the neurosurgical and neurocritical care literature. ⋯ In addition, lower HTS concentrations strongly correlated with greater ICP reduction. Therefore, lower concentrations of HTS may be practical therapeutic agents for patients with TBI given their efficacy in ICP reduction and safer complication profile compared with greater HTS concentrations. Evidence-based parametric use of HTS stands to improve patient outcomes by standardization of varied clinical practice.
-
Thoracolumbar burst fracture without neurological deficit is a common spinal injury. The ideal classification for the diagnosis and the optimal management strategies, including conservative management, surgical approach, implant constructs, need for spinal fusion, and implant removal, are controversial and currently being investigated. This article reviews the current literature to provide updated evidence on these topics. ⋯ Spinal fusion is not necessary for this type of injury. Minimally invasive surgery techniques provide equivalent outcomes and can safely replace open approaches. Implant removal after stabilization may provide some benefits, especially in younger patients.
-
Isocitrate dehydrogenase (IDH) mutations are present in 70% of World Health Organization grade II and III gliomas. IDH mutation induces accumulation of the oncometabolite 2-hydroxyglutarate. Therefore, therapies targeting reversal of epigenetic dysregulation in gliomas have been suggested. However, the utility of epigenetic treatments in gliomas remains unclear. Here, we present the first clinical systematic review of epigenetic therapies in treatment of IDH-mutant gliomas and highlight their safety and efficacy. ⋯ IDH inhibitors appear promising given their benign toxicity profile and ease of monitoring. Histone deacetylase inhibitors appear to have a narrow therapeutic index, as lower concentrations do not appear effective, while increased doses can produce severe immunosuppressive effects. Preliminary data suggest that epigenetic therapies are generally well tolerated and may control disease in certain patient groups, such as those with nonenhancing lesions.