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

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

Three versus seven days to return-to-work after mild traumatic brain injury: a randomised parallel-group trial with neuropsychological assessment

Although most patients with a mild traumatic brain injury (mTBI) recover within days to weeks, some experience persistent physical, cognitive and emotional symptoms, often described as postconcussion syndrome (PCS). The optimal recovery time including return-to-work (RTW) after mTBI is unclear. In this single-centre parallel-group trial, patients assigned three days (3D-group) or seven days (7D-group) sick leave were compared with a comprehensive neuropsychological test battery including the Post Concussion Symptom Scale (PCSS) within one week, after three and twelve months post-injury. The influence of the effective time until RTW on postconcussional symptoms and cognitive performance was analyzed. The 3D-group rated significantly higher mean scores in some PCSS symptoms, tended to fulfil diagnosis criteria of PCS more often and showed better cognitive performance in several neuropsychological test scores than the 7D-group at all three time-points of follow-up. Overall, patients returned to work 11.35 days post injury, thus distinctly above both recommended sick leaves. There was a trend for longer sick leave in patients randomized into the 3D-group. Further analyses revealed that the group with an absolute RTW within one week showed lower symptom severity in fatigue at three and twelve months, less PCS and faster performance in fine motor speed at twelve months than the group with an absolute RTW after one week. Our data underline the heterogeneity of mTBI and shows that acute and sub-acute symptoms are not prognostic factors for neuropsychological outcome at one year. Later ability to work seems to be prognostic for long-term occurrence of PCS

Changes of cerebral blood flow during the secondary expansion of a cortical contusion assessed by <tex>^{14}C$</tex>-iodoantipyrine autoradiography in mice using a non-invasive protocol

Although changes of cerebral blood flow (CBF) in and around traumatic contusions are well documented, the role of CBF for the delayed death of neuronal cells in the traumatic penumbra ultimately resulting in secondary contusion expansion remains unclear. The aim of the current study was therefore to investigate the relationship between changes of CBF and progressive peri-contusional cell death following traumatic brain injury (TBI). CBF and contusion size were measured in C57Bl6 mice under continuous on-line monitoring of ETpCO2 before, and at 15 min and 24 h following controlled cortical impact by C-14-iodoantipyrine autoradiography (IAP-AR; n = 5-6 per group) and by Nissl staining, respectively. Contused and ischemic (CBF < 10%) tissue volumes were calculated and compared over time. Cortical CBF in not injured mice varied between 69 and 93 mL/100mg/min depending on the anatomical location. Fifteen minutes after trauma, CBF decreased in the whole brain by similar to 50% (39 +/- 18 mL/100mg/min; p < 0.05), except in contused tissue where it fell by more than 90% (3 +/- 2 mL/100mg/min; p < 0.001). Within 24 h after TBI, CBF recovered to normal values in all brain areas except the contusion where it remained reduced by more than 90% (p < 0.001). Contusion volume expanded from 24.9 to 35.5 mm3 (p < 0.01) from 15 min to 24 h after trauma (+43%), whereas the area of severe ischemia (CBF < 10%) showed only a minimal (+13%) and not significant increase (22.3 to 25.1 mm(3)). The current data therefore suggest that the delayed secondary expansion of a cortical contusion following traumatic brain injury may not be caused by a reduction of CBF alone