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
A chronic subdural hematoma (CSDH) is an intracranial bleeding between the outer two meninges of the brain due to rupture of cerebral veins or an inflammatory response in the subdural space.... Show moreA chronic subdural hematoma (CSDH) is an intracranial bleeding between the outer two meninges of the brain due to rupture of cerebral veins or an inflammatory response in the subdural space. Elderly patients using anti-thrombotic therapy are at higher risk for hematoma development. A rise in CSDH incidence is expected because of the aging population and increase in anti-thrombotic therapy use due to cardiovascular disease. To date, no treatment guideline exists regarding optimal CSDH treatment. Surgery with subdural drainage is the mainstay treatment. However, due to relevant surgical complications, a recurrence risk up to 30% and increased mortality in this vulnerable patient population, corticosteroid therapy is being administered as an alternative or adjuvant treatment modality.In this thesis we have shown that surgical treatment results in significantly better treatment outcome than medicinal approach by the corticosteroid dexamethasone in a retrospective study (chapter 2) as well as in a randomized controlled trial (chapter 3 and 4). Furthermore, we revealed radiological markers that are of prognostic value to predict treatment outcome after surgery (chapter 5) and dexamethasone therapy (chapter 6) in symptomatic CSDH patients. Show less
Even after thousands of years of experience in treating patients with TBI, decisions regarding the optimal treatment strategy remain difficult for both healthcare workers as policy makers. The... Show moreEven after thousands of years of experience in treating patients with TBI, decisions regarding the optimal treatment strategy remain difficult for both healthcare workers as policy makers. The first part of this thesis investigated the challenges of the treatment decision-making process in patients with (severe) TBI by focussing on three factors considered to be important in this process: patient outcome, in-hospital healthcare consumption, and in-hospital costs. The second part investigated the procedural difficulties in TBI research efficiency by focussing on the process of institutional review board approval and the use of informed consent procedures in patients with TBI with an inability to provide informed consent. Finally, we elaborate on the role of patient outcome and in-hospital costs in the acute treatment decision-making process in patients with severe TBI and make suggestions to optimize future research initiatives. Show less
Pituitary insufficiency in the presence of a pituitary macroadenoma or after pituitary irradiation is frequently reported. In addition, pituitary insufficiency is increasingly reported after... Show morePituitary insufficiency in the presence of a pituitary macroadenoma or after pituitary irradiation is frequently reported. In addition, pituitary insufficiency is increasingly reported after traumatic head injuries. The correct evaluation and interpretation, however, of the pituitary axes, and consequently, the potential therapeutical consequences are a matter of controversies. The studies reported in this thesis aim to provide better insight into the complexity of different endocrine tests used for the evaluation of possible pituitary insufficiency and in the treatment of patients with pituitary insufficiency. Show less
