A traumatic acute subdural hematoma, a bleeding between the skull and the brain after a traumatic injury, is associated with high mortality and long-term neurocognitive morbidity. One of the age... Show moreA traumatic acute subdural hematoma, a bleeding between the skull and the brain after a traumatic injury, is associated with high mortality and long-term neurocognitive morbidity. One of the age-old cornerstones of treatment is immediate neurosurgical management, with either acute hematoma evacuation or initial conservative treatment with potential delayed surgery. In patients with rapid neurological deterioration because of a large acute subdural hematoma, the indication is clear; without acute surgery, high intracranial pressure will persist and the patient will die. In most cases however, the benefit of acute surgery is less clear, and patients may, at least initially, be managed conservatively. This strategy requires balancing potential complications of surgery against the risk of irreversible neurological deterioration with initial conservative treatment.Neurosurgeon Thomas van Essen first shows that appropriate evidence of acute surgery versus conservative treatment for acute subdural hematoma is lacking, although among comatose patients, acute surgery has a clear benefit. Subsequently, he demonstrates that among neurosurgeons treatment preferences strongly and consistently differ, resulting in large practice variations. Using these treatment preferences, he then shows that patients treated in centers that prefer acute surgery (over conservative treatment) have equal outcomes to patients treated in centers that prefer conservative treatment. Additionally, with regard to surgical technique, primary decompressive craniectomy - leaving the bone flap out after evacuation of the acute subdural hematoma - might not lead to better outcomes as compared to craniotomy – replacing the bone flap directly. The thesis has practical implications for clinical practice: When the neurosurgeon has no clear preference for acute surgery or conservative treatment, treat patients with a traumatic acute subdural hematoma conservatively. And, primary decompressive craniectomy in traumatic acute subdural hematoma should be restricted to patients in whom replacement of the bone flap is not possible due to severe brain swelling. Show less
Traumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary... Show moreTraumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary insults and optimizing the balance between substrate delivery and consumption. Over the past decades, multimodality monitoring has become more widely available, and clinical management protocols have been published that recommend potential interventions to correct pathophysiological derangements. Even while evidence from randomized clinical trials is still lacking for many of the recommended interventions, these protocols and algorithms can be useful to define a clear standard of therapy where novel interventions can be added or be compared to. Over the past decade, more attention has been paid to holistic management, in which hemodynamic, respiratory, inflammatory or coagulation disturbances are detected and treated accordingly. Considerable variability with regards to the trajectories of recovery exists. Even while most of the recovery occurs in the first months after TBI, substantial changes may still occur in a later phase. Neuroprognostication is challenging in these patients, where a risk of self-fulfilling prophecies is a matter of concern. The present article provides a comprehensive and practical review of the current best practice in clinical management and long-term outcomes of moderate to severe TBI in adult patients admitted to the intensive care unit. Show less
Kleij, L.A. van der; Vis, J.B. de; Bresser, J. de; Hendrikse, J.; Siero, J.C.W. 2020
The Monro-Kellie hypothesis (MKH) states that volume changes in any intracranial component (blood, brain tissue, cerebrospinal fluid) should be counterbalanced by a co-occurring opposite change to... Show moreThe Monro-Kellie hypothesis (MKH) states that volume changes in any intracranial component (blood, brain tissue, cerebrospinal fluid) should be counterbalanced by a co-occurring opposite change to maintain intracranial pressure within the fixed volume of the cranium. In this feasibility study, we investigate the MKH application to structural magnetic resonance imaging (MRI) in observing compensating intracranial volume changes during hypercapnia, which causes an increase in cerebral blood volume. Seven healthy subjects aged from 24 to 64 years (median 32), 4 males and 3 females, underwent a 3-T three-dimensional T1-weighted MRI under normocapnia and under hypercapnia. Intracranial tissue volumes were computed. According to the MKH, the significant increase in measured brain parenchymal volume (median 6.0 mL; interquartile range 4.5, 8.5; p = 0.016) during hypercapnia co-occurred with a decrease in intracranial cerebrospinal fluid (median -10.0 mL; interquartile range -13.5, -6.5; p = 0.034). These results convey several implications: (i) blood volume changes either caused by disorders, anaesthesia, or medication can affect outcome of brain volumetric studies; (ii) besides probing tissue displacement, this approach may assess the brain cerebrovascular reactivity. Future studies should explore the use of alternative sequences, such as three-dimensional T2-weighted imaging, for improved quantification of hypercapnia-induced volume changes. Show less
Purpose To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers.... Show morePurpose To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers. Methods This is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient- and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers. Results A total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13-15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatments (MOR = 2.9, p < 0.001); and smaller in 6-month outcome (MOR = 1.2, p = 0.01). Conclusions Half of contemporary TBI patients at the ICU have mild to moderate head injury. Substantial between-center variations exist in ICU stay and treatment policies, and less so in outcome. It remains unclear whether admission of short-stay patients represents appropriate prudence or inappropriate use of clinical resources. Show less
Goedemans, T.; Veer, O. van der; Verbaan, D.; Bot, M.; Lequin, M.B.; Coert, B.A.; ... ; Munckhof, P. van den 2018
