Secondary Damage after Traumatic Brain Injury: Epidemiology, Pathophysiology and Therapy

Traumatic brain injury (TBI) is defined as a microscopic or macroscopic injury to the brain caused by external physical forces. Road traffic accidents, falls, sports injuries (i.e. boxing), recreational accidents (i.e. parachute jumping), the use of firearms, assault, child abuse, and several rare causes e.g. the use of nail guns or lawn mowers have all been described as causes of TBI. The pathology of TBI can be classified by mechanism (closed versus penetrating); clinical severity (Glasgow Coma Scale) and structural damage (imaging e.g. CT-examination). In most cases TBI is graded according to injury severity assessing the level of consciousness of the patient by, most frequently, the Glasgow Coma Scale (GCS). The GCS scores patients based on their ability to open their eyes, perform limb movements and respond adequately to simple questions (Teasdale and Jennett 1974) (see table 1). Mild TBI, e.g. a light concussion, is defined as a patient with a GCS of 13-15 possibly suffering from short-term memory and concentration deficits (Rimel et al., 1981; Mosenthal et al., 2004). Moderate TBI is scored by a GCS of 9-12, e.g. a lethargic and stuporous patient. A comatose patient, unable to open eyes or follow commands has been severely injured and has a GCS of 3-8

Reasonability of implementation of the endoscopic technique for sellar lesions in a low volume center

AbstractWe evaluated the implementation of the endoscopic (E) technique by an interdisciplinary ENT/neurosurgeon team as compared to the established classical microscopic technique (M) performed by one experienced neurosurgeon for pituitary adenomas in a single center. A retrospective analysis of patients operated for newly diagnosed pituitary adenomas was performed between November 2004 and August 2012. Outcome and complications are presented. A total of 116 patients were operated, 64 microscopically (M) and 52 endoscopically (E). Mean follow up was 35months (range 1.4–95), 1 patient was lost to follow-up. Most frequent pathology was hormone inactive adenoma (60% E, 51% M). Operating time was stable in the M-group (±94min). The E-group showed a learning curve in mean operating time (2004–2007: 154min, 2008–2012: 93min). Postoperative CSF leaks were seen in 9.6% (E) vs. 3.1% (M) of cases. More E-cases were re-operated (5 vs. 1) and more M-cases received a lumbar drainage (8 vs. 19). Transient postoperative diabetes insipidus occurred more often after E-operations (17 vs. 5%, p=0.03) without significant long term difference. Improved visual outcome showed a more favorable trend in E-cases. The implementation of the endoscopic technique was associated with more surgical complications in the learning phase, however with more improved visual outcome. Our observations should be of value for the more average neurosurgical department dealing with pituitary adenomas and aiming to switch from the microscopic to the endoscopic technique

Trigeminal Neuralgia Type 1: Earlier Microvascular Decompression is Associated with Improved Outcome

Background: Medication therapy is commonly accepted as the initial treatment of trigeminal neuralgia (TN). Microvascular decompression (MVD) is the surgical treatment with the highest efficacy, but is considered as last tier therapy for patients with medication refractory pain or for those with unbearable side effects. The aim of this study was to investigate the association of symptom duration on outcome. Methods: A retrospective study was conducted from 2001 through 2012. Patients were categorized according to Burchiel’s “Classification scheme for facial pains commonly encountered in neurosurgical practice”. Demographical, disease and treatment data as well as surgical data including complications and outcome were recorded and analyzed. Results: In total, 65 patients were included. Distribution of diagnoses was as follows: TN type 1 (>50% episodic pain) n=54, TN type 2 (>50% constant pain) n=4, neuropathic TN n=1, symptomatic TN due to multiple sclerosis n=3, post herpetic n=2. Onset of disease to surgery was on average 7 years (<1-21 years). Shorter time from disease onset to surgery had a statistically significant association with a pain-free outcome in only TN type 1 patients (6 vs. 13 years, p=0.01). Overall success rate in TN1 was 88.9%. Overall mortality and morbidity rate were 3%. Overall complication rate was 13.5%. Conclusion: Earlier MVD was significantly associated with better outcome. Patients should be informed about the option of MVD at an early stage of disease

Common Data Elements for Traumatic Brain Injury: Recommendations From the Biospecimens and Biomarkers Working Group

Recent advances in genomics, proteomics, and biotechnology have provided unprecedented opportunities for translational research and personalized medicine. Human biospecimens and biofluids represent an important resource from which molecular data can be generated to detect and classify injury and to identify molecular mechanisms and therapeutic targets. To date, there has been considerable variability in biospecimen and biofluid collection, storage, and processing in traumatic brain injury (TBI) studies. To realize the full potential of this important resource, standardization and adoption of best practice guidelines are required to insure the quality and consistency of these specimens. The aim of the Biospecimens and Biomarkers Working Group was to provide recommendations for core data elements for TBI research and develop best practice guidelines to standardize the quality and accessibility of these specimens. Consensus recommendations were developed through interactions with focus groups and input from stakeholders participating in the interagency workshop on Standardization of Data Collection in TBI and Psychological Health held in Washington, DC, in March 2009. With the adoption of these standards and best practices, future investigators will be able to obtain data across multiple studies with reduced costs and effort and accelerate the progress of genomic, proteomic, and metabolomic research in TBI

Results from Canton Grisons of Switzerland suggest repetitive testing reduces SARS-CoV-2 incidence (February-March 2021).

In February 2021, in response to emergence of more transmissible SARS-CoV-2 virus variants, the Canton Grisons launched a unique RNA mass testing program targeting the labour force in local businesses. Employees were offered weekly tests free of charge and on a voluntary basis. If tested positive, they were required to self-isolate for ten days and their contacts were subjected to daily testing at work. Thereby, the quarantine of contact persons could be waved.Here, we evaluate the effects of the testing program on the tested cohorts. We examined 121,364 test results from 27,514 participants during February-March 2021. By distinguishing different cohorts of employees, we observe a noticeable decrease in the test positivity rate and a statistically significant reduction in the associated incidence rate over the considered period. The reduction in the latter ranges between 18 and 50%. The variability is partly explained by different exposures to exogenous infection sources (e.g., contacts with visiting tourists or cross-border commuters). Our analysis provides the first empirical evidence that applying repetitive mass testing to a real population over an extended period of time can prevent spread of COVID-19 pandemic. However, to overcome logistic, uptake, and adherence challenges it is important that the program is carefully designed and that disease incursion from the population outside of the program is considered and controlled

Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial.

IMPORTANCE After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome. OBJECTIVE To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage. DESIGN, SETTING, AND PARTICIPANTS The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. INTERVENTION A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. MAIN OUTCOMES AND MEASURES Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage. RESULTS Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04). CONCLUSION AND RELEVANCE In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01258257