Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma.

BACKGROUND: Acute subdural hematoma (ASDH) is a traumatic lesion commonly found secondary to traumatic brain injury. Radiological findings on CT, such as hematoma thickness (HT) and structures midline shift (MLS), have an important prognostic role in this disease. The relationship between HT and MLS has been rarely studied in the literature. Thus, this study aimed to assess the prognostic accuracy of the difference between MLS and HT for acute outcomes in patients with ASDH in a low-income to middle-income country. METHODS: This was a post-hoc analysis of a prospective cohort study conducted in a university-associated tertiary-level hospital in Brazil. The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis) statement guidelines were followed. The difference values between MLS and HT (Zumkeller index, ZI) were divided into three categories (3). Logistic regression analyses were performed to reveal the OR of categorized ZI in predicting primary outcome measures. A Cox regression was also performed and the results were presented through HR. The discriminative ability of three multivariate models including clinical and radiological variables (ZI, Rotterdam score, and Helsinki score) was demonstrated. RESULTS: A total of 114 patients were included. Logistic regression demonstrated an OR value equal to 8.12 for the ZI >3 category (OR 8.12, 95% CI 1.16 to 40.01; p=0.01), which proved to be an independent predictor of mortality in the adjusted model for surgical intervention, age, and Glasgow Coma Scale (GCS) score. Cox regression analysis demonstrated that this category was associated with 14-day survival (HR 2.92, 95% CI 1.38 to 6.16; p=0.005). A multivariate analysis performed for three models including age and GCS with categorized ZI or Helsinki or Rotterdam score demonstrated area under the receiver operating characteristic curve values of 0.745, 0.767, and 0.808, respectively. CONCLUSIONS: The present study highlights the potential usefulness of the difference between MLS and HT as a prognostic variable in patients with ASDH. LEVEL OF EVIDENCE: Level III, epidemiological study

Neurosurgeons' experiences of conducting and disseminating clinical research in low-income and middle-income countries: a reflexive thematic analysis.

OBJECTIVES: Low-income and-middle-income countries (LMICs) are increasing investment in research and development, yet there remains a paucity of neurotrauma research published by those in LMICs. The aim of this study was to understand neurosurgeons' experiences of, aspirations for, and ability to conduct and disseminate clinical research in LMICs. DESIGN: This was a two-stage inductive qualitative study situated within the naturalistic paradigm. This study committed to an interpretivist way of knowing (epistemology), and considered reality subjective and multiple (ontology). Data collection used online methods and included a web-based survey tool for demographic data, an asynchronous online focus group and follow-up semistructured interviews. Data were analysed using Braun and Clarke's Reflexive Thematic Analysis supported by NVivo V.12. SETTING: LMICs. PARTICIPANTS: In April-July 2020, 26 neurosurgeons from 11 LMICs participated in this study (n=24 in the focus groups, n=20 in follow-up interviews). RESULTS: The analysis gave rise to five themes: The local landscape; creating capacity; reach and impact; collaborative inquiry; growth and sustainability. Each theme contained an inhibitor and stimulus to neurosurgeons conducting and disseminating clinical research, interpreted as 'the neurosurgical research potential in LMICs'. Mentorship, education, infrastructure, impact and engagement were identified as specific accelerators. Whereas lack of generalisability, absence of dissemination and dissemination without peer review may desensitise the impact of research conducted by neurosurgeons. CONCLUSION: The geographical, political and population complexities make research endeavour challenging for neurosurgeons in LMICs. Yet in spite of, and because of, these complexities LMICs provide rich opportunities to advance global neurosurgery. More studies are required to evaluate the specific effects of accelerators of research conducted by neurosurgeons and to understand the effects of desensitisers on high-quality, high-impact clinical research

Decompressive craniotomy: an international survey of practice.

Funder: National Institute for Health Research; doi: http://dx.doi.org/10.13039/501100000272Funder: University of Cambridge and the Royal College of Surgeons of EnglandBACKGROUND: Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide. METHOD: A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019. RESULTS: We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC. CONCLUSION: Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial

Outcomes of surgical and endovascular treatments for fusiform intracranial aneurysms: systematic review and individual participant data meta-analysis

Introduction: We propose a systematic review and meta-analysis of individual participant data with propensity-score adjustment to compare the functional and angiographic outcomes between surgical and endovascular approaches to FIA. Methods: We conducted a systematic review based on the PRISMA-IPD guidelines for articles published on the treatment of FIA with individual patient-level detailing. The primary studied outcome was morbidity, and secondary outcomes were angiographic results, recanalization, and retreatment.Results: Individual data were available for 296 patients in 29 studies. Out of 73 surgical cases, the commonest option was bypassing, combined with clipping, trapping, or excision (N=38, 52.1%). Out of 223 endovascular cases, stenting was the primary choice (N=127, 56.9%). Post-procedure morbidity inflicted 75 patients (25%), of which 22 had been submitted to open procedures (30.1%), and 53 had been treated endovascularly (23.8%). Crude models studied the relationship between surgical treatment and morbidity overall and within each location, and there were no significant associations (Figure 2, all P > 0.05). A final multivariable model was fitted, including the covariates rupture status, initial mRS, size, and age (Figure 3). Each additional score in the initial mRS was associated with an odds ratio of 1.79 of post-procedure morbidity (95% CI 1.24 – 2.6). No differences were detected between surgical and endovascular (OR 0.95, 95% CI 0.18-5.11). Conclusion: Comparing surgical and endovascular procedures, no differences were observed on post-procedure morbidity regardless of aneurysm location. A smaller percentage of unfavorable angiographic outcomes was reported after open procedures, but larger studies are necessary to evaluate those associations

False claims of equivalence in the neurosurgical trauma literature - Protocol

Introduction: Research quality within the neurosurgical field remains suboptimal. Therefore, many studies published in the neurosurgical literature lack enough statistical power to establish the presence or absence of clinically important differences between treatment arms. The field of neurotrauma deals with additional challenges, with fewer financial incentives and restricted resources in low- and middle-income countries with the highest burden of neurotrauma diseases. In this systematic review, we aimed to estimate the prevalence of false claims of equivalence in the neurosurgical trauma literature and identify its predictive factors. Methods and analysis: The Preferred Reporting Item for Systematic review and Meta-Analyses (PRISMA) recommendations were followed. Randomized clinical trials (RCT) that enrolled only traumatic brain injury (TBI) patients and investigated any type of intervention (surgical or non-surgical) were eligible for inclusion. The MEDLINE / PubMed database was searched for articles in English published from 1960 to 2020 in fifteen top-ranked journals. A false claim of equivalence will be identified by an insufficient power to detect a clinically meaningful effect: for categorical outcomes, a difference of at least 25% and 50%; for continuous outcomes, a Cohen’s d of at least 0.5 and 0.8. Using the number of patients in each treatment arm and the minimum effect sizes to be detected, the power of each study will be calculated with the assumption of a two-tailed α equals .05. Standardized differences between the groups with or without a false claim of equivalence will be calculated and the variables with a standardized difference equal or above 0.2 and 0.5 will be considered weakly and strongly associated with false claims of equivalence respectively. The data analysis will be blinded to the authors and institutions of the studies. Ethics and dissemination: This study will not involve primary data collection. Therefore, formal ethical approval will not be required