Decompressive craniectomy: Technical note

Decompressive craniectomy is a neurosurgical technique in which a portion of the skull is removed to reduce intracranial pressure. The rationale for this procedure is based on the Monro-Kellie Doctrine; expanding the physical space confining edematous brain tissue after traumatic brain injury will reduce intracranial pressure. There is significant debate over the efficacy of decompressive craniectomy despite its sound rationale and historical significance. Considerable variation in the employment of decompressive craniectomy, particularly for secondary brain injury, explains the inconsistent results and mixed opinions of this potentially valuable technique. One way to address these concerns is to establish a consistent methodology for performing decompressive craniectomies. The purpose of this paper is to begin accomplishing this goal and to emphasize the critical points of the hemicraniectomy and bicoronal (Kjellberg type) craniectomy. © 2010 John Wiley & Sons A/S

Neurosurgery in tanzania: A discussion of culture, socioeconomics, and humanitarians

Objective: To elucidate the progress of neurosurgical practices in Tanzania, taking into account humanitarian, socioeconomic, and geographic influences. Method: Articles, records, and historical texts were consulted to establish a timeline and history of neurosurgery in Tanzania. Results: Reulen, a German neurosurgeon, was integral to the development of sustainable neurosurgical services in Tanzania. By training Tanzanians who returned to their country to practice, Reulen helped to establish a continuity of care and legacy on which future Tanzanian surgeons could build. Subsequently, as neurosurgical services were integrated into the Muhimbili Orthopedic Institute, surgeons found a hospital to call home and a place to focus their efforts. Neurosurgical services have now been offered to the Tanzanian people for \u3e40 years, a direct consequence of international influences coupled with certain extraordinary Tanzanian physicians. Conclusions: Neurosurgery in Tanzania and Africa more generally has a long history; however, it was not until more recent efforts of certain local pioneers and educational advisors abroad that modernization occurred. The progress of the past 50 years is substantial and with continued efforts advances will continue to be made. © 2012 Elsevier Inc

Saline Versus Balanced Crystalloids for Adults With Aneurysmal Subarachnoid Hemorrhage: A Subgroup Analysis of the SMART Trial

Background Whether the composition of intravenous crystalloid solutions affects outcomes in adults with aneurysmal subarachnoid hemorrhage (aSAH) remains unknown. Therefore, we determined whether the use of saline is associated with a lower risk of disability and death in patients with aSAH compared with balanced crystalloids. Methods We conducted a post hoc subgroup analysis of SMART (Isotonic Solutions and Major Adverse Renal Events Trial), a pragmatic, unblinded, cluster‐randomized, multiple‐crossover clinical trial that enrolled 15 802 adults between June 2015 and April 2017. We compared IV administration of saline to balanced crystalloids in consecutively enrolled patients with aSAH aged 18 years or older whose ruptured aneurysm was procedurally secured at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms]–6 [death]) at 90 days obtained from a prospective institutional stroke registry. Secondary outcome included death by 90 days. Logistic or proportional odds regression models were used to test for between‐group differences adjusted for age, hypertension, aSAH grade, and procedure type. Results Of the 79 patients with aSAH procedurally treated during the Isotonic Solutions and Major Adverse Renal Events Trial study period, 78 were enrolled (median age, 58 years; interquartile range, 49–64.5; 64% female), with 41 (53%) assigned to saline and 37 (47%) to balanced crystalloids. Plasma‐Lyte was the primary balanced crystalloid used. Among 72 patients with 90‐day modified Rankin scale assessment, the adjusted common odds ratio, for the modified Rankin scale was 0.68 (95% CI, 0.28–1.63; P=0.39), with values <1.0 favoring saline. By 90 days, 2/39 patients (5%) in the saline group and 9/35 (26%) in the balanced‐crystalloids group had died (adjusted common odds ratio, 0.06; 95% CI, 0.00–0.50; P=0.02). Conclusions Among procedurally treated patients with aSAH, the risk of disability or death at 90 days did not significantly differ between saline and balanced crystalloids. Death occurred less frequently with saline than balanced crystalloids