Magnesium: Pathophysiological mechanisms and potential therapeutic roles in intracerebral hemorrhage

Intracerebral hemorrhage (ICH) remains the second-most common form of stroke with high morbidity and mortality. ICH can be divided into two pathophysiological stages: an acute primary phase, including hematoma volume expansion, and a subacute secondary phase consisting of blood-brain barrier disruption and perihematomal edema expansion. To date, all major trials for ICH have targeted the primary phase with therapies designed to reduce hematoma expansion through blood pressure control, surgical evacuation, and hemostasis. However, none of these trials has resulted in improved clinical outcomes. Magnesium is a ubiquitous element that also plays roles in vasodilation, hemostasis, and blood-brain barrier preservation. Animal models have highlighted potential therapeutic roles for magnesium in neurological diseases specifically targeting these pathophysiological mechanisms. Retrospective studies have also demonstrated inverse associations between admission magnesium levels and hematoma volume, hematoma expansion, and clinical outcome in patients with ICH. These associations, coupled with the multifactorial role of magnesium that targets both primary and secondary phases of ICH, suggest that magnesium may be a viable target of study in future ICH studies

Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)

Management; Transfer; Traumatic brain injuryGestión; Transferir; Lesión cerebral traumáticaGestió; Transferència; Lesió cerebral traumàticaBackground Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care. Methods A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted. Results A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided. Conclusions This consensus provides practical recommendations to support clinician’s decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center

Foreign-Body Reaction Mimicking Postneurosurgical Infection After Cranioplasty

The case of a 57-year-old woman who suffered a fall is presented. After a polymethyl malacrylate revision cranioplasty, she presented with signs, symptoms, and intraoperative findings consistent with postneurosurgical infection. Dural foreign-body reaction was diagnosed, and parenteral antibiotic therapy was discontinued successfully

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care : a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine.

Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data

Monitoring of cerebral blood flow and ischemia in the critically ill

Secondary ischemic injury is common after acute brain injury and can be evaluated with the use of neuromonitoring devices. This manuscript provides guidelines for the use of devices to monitor cerebral blood flow (CBF) in critically ill patients. A Medline search was conducted to address essential pre-specified questions related to the utility of CBF monitoring. Peer-reviewed recommendations were constructed according to the GRADE criteria based upon the available supporting literature. Transcranial Doppler ultrasonography (TCD) and transcranial color-coded duplex sonography (TCCS) are predictive of angiographic vasospasm and delayed ischemic neurological deficits after aneurysmal subarachnoid hemorrhage. TCD and TCCS may be beneficial in identifying vasospasm after traumatic brain injury. TCD and TCCS have shortcomings in identifying some secondary ischemic risks. Implantable thermal diffusion flowmetry (TDF) probes may provide real-time continuous quantitative assessment of ischemic risks. Data are lacking regarding ischemic thresholds for TDF or their correlation with ischemic injury and clinical outcomes.TCD and TCCS can be used to monitor CBF in the neurocritical care unit. Better and more developed methods of continuous CBF monitoring are needed to limit secondary ischemic injury in the neurocritical care unit

Wartime traumatic aneurysms: acute presentation, diagnosis, and multimodal treatment of 64 craniocervical arterial injuries.

OBJECTIVE: Operation Iraqi Freedom has resulted in a significant number of closed and penetrating head injuries, and a consequence of both has been the accompanying neurovascular injuries. Here we review the largest reported population of patients with traumatic neurovascular disease and offer our experience with both endovascular and surgical management. METHODS: A retrospective analysis of all military casualties returning to the Walter Reed Army Medical Center and the National Naval Medical Center, Bethesda, Maryland, from April 2003 until April 2008 was performed. All patients undergoing diagnostic cerebral angiography during their inpatient stay were included in the study. RESULTS: A total of 513 war trauma-related consults were performed from April 2003 to April 2008, resulting in the evaluation of 408 patients with closed and penetrating head injuries. In this population, 279 angiographic studies were performed in 187 patients (25 closed craniocervical injuries, 162 penetrating craniocervical injuries), resulting in the detection of 64 vascular injuries in 48 patients (26.2% of those studied, 34% prevalence). Vascular injuries were characterized by traumatic intracranial aneurysms (TICAs) (n = 31), traumatic extracalvarial aneurysms (TECAs) (n = 19), arterial dissections (n = 11), and arteriovenous fistulae (n = 3). The average TICA size on admission was 4.1 mm, with an observed increase in aneurysm size in 11 cases. In the TICA/TECA group, 24 aneurysms in 23 patients were treated endovascularly with either coiling or stent-assisted coiling, resulting in preservation of the parent artery in 12 of 24 vessels (50%). The injuries in 3 patients in this group progressed despite endovascular treatment and required definitive clip exclusion. Thirteen additional aneurysms in 8 patients were treated surgically, resulting in parent artery preservation in 4 cases (30.8%). Eleven of the 13 remaining TICAs/TECAs resolved spontaneously without treatment. A total of 6 aneurysm ruptures (average size, 8.25 mm) occurred, resulting in 3 deaths. Four of 6 ruptures occurred in TICAs in which the interval size increase was noted angiographically. CONCLUSION: The management of traumatic vascular injury has evolved with technological advancement and the willingness of the neurosurgeon to intervene. Although open surgical intervention remains a viable solution, endovascular options are available and safe and can effectively temporize a patient while acute sequelae of serious head injury resolve

The evolution of the treatment of traumatic cerebrovascular injury during wartime.

The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. The current conflicts have seen dramatic improvements with respect to the management of severe penetrating and closed head injuries. As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors\u27 purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized

Intracranial aneurysms treatment using new generation FRED X flow diverters with antithrombotic coating and preoperative PreSize Neurovascular software simulation: literature review and own clinical observations analysis

Objective: Evaluate the possibilities of treating giant intracranial aneurysms and complex anatomy aneurysms by implanting new generation of FRED X flow diverters (MicroVention, USA) with antithrombogenic surface subject to preoperative virtual modeling and sizing with PreSize Neurovascular software (Oxford Heartbeat Ltd, Great Britain). Materials and Methods. FRED X flow diverters with antithrombogenic surface were implanted in 7 patients with giant cerebral aneurysms and complex anatomy aneurysms in the Endovascular Center at Mechnikov Dnipropetrovsk Regional Clinical Hospital, Dnipro, within two months (May 2, 2023 to June 27, 2023). Our study group consisted of 4 (57.1%) female patients and 3 (42.9%) male patients (p=1.0). The average age was 50.4±13.7. 4 patients had single intracranial aneurysms and 3 patients had multiple aneurysms. 2 patients had 2 aneurysms and 1 patient had 4 aneurysms. 3 patients had a hemorrhagic clinical course of the disease (spontaneous subarachnoid hemorrhage in the history), 3 patients had asymptomatic aneurysms, and 1 patient had a pseudotumorous aneurysm. Results. All 7 patients underwent the ICA aneurysm(s) surgery. 3 patients had a flow diverter implanted at the level of multiple aneurysms (in 2 patients, 2 aneurysms; in 1 patient, 3 aneurysms). 2 patients, in addition to flow diverter implantation, underwent coil aneurysms embolization (using jailing technique). In all patients, the flow diverter was implanted under dual (ticagrelor and acetylsalicylic acid) antiplatelet therapy. 3 patients with a history of subarachnoid aneurysmal hemorrhage received a loading dose of dual antiplatelet therapy immediately before the flow diverter implantation. In one patient with a complex closed siphon shape, balloon angioplasty was required to optimize flow diverter opening to the arterial wall. In all other 6 patients, the flow diverters were opened in a controlled manner with a Push & Pull technique variant: Load/Tension Unsheath technique. Conclusions: In the endovascular treatment of giant and complex aneurysms, the use of new generation FRED X flow diverters (MicroVention, USA) with antithrombogenic coating subject to proper diverters sizing with PreSize Neurovascular software does not cause technical difficulties and is controlled