Extracellular fluid astroglial markers of brain injury after subarachnoid haemorrhage

Inroduction: Despite the great strides that have been made during the modern era of cerebrovascular surgery, subarachnoid haemorrhage (SAH) remains a devastating illness. Approximately 12% of patients die before receiving medical attention, 40% of hospitalized patients die within one month after the event, and more than one third of those who survive have major neurological deficits and will be dependent on others for activities of daily living. The prognosis of patients surviving the initial ictus and reaching hospital care is mainly aggravated by a number of secondary insults (cerebral vasospasm, intracranial hypertension, rebleeding, seizures, hydrocephalus, ischaemia, hypoxia) which commonly complicate their in-hospital clinical course. Earlier detection of these insults would enable us to treat them in a more timely and aggressive manner biochemical markers could certainly contribute to this goal. Our hypothesis is that certain substances released into brain extracellular fluid (ECF) during the primary and secondary insults could correlate with or even precede clinical manifestations of secondary insults, and act as predictors of short and long-term outcome. We chose to focus on two astroglial proteins, namely S100B and glial fibrillary acidic protein (GFAP), as the astrocytes play a critical role in the regulation of brain homeostasis at the cellular level, and they are immediately activated after the initial ictus. Moreover, both proteins have shown some promising results when measured in serum, cerebrospinal fluid (CSF), and ECF

A Retrospective Cohort Study to Assess Patient and Physician Reported Outcome Measures After Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke.

INTRODUCTION: Decompressive hemicraniectomy for malignant middle cerebral artery (MCA) infarction is known to reduce mortality. However, there are on-going concerns in terms of the quality of life in survivors. We aimed to examine the correlation between patient and physician reported outcome measures in decompressive hemicraniectomy. PATIENTS AND METHODS: We analyzed outcomes in 21 patients who underwent decompressive hemicraniectomy for malignant MCA infarction between September 2003 and August 2013 within a regional health system. Patient and physician reported outcome measures were collected at follow-up. These were Stroke Impact Scale (SIS) Version 3, modified Rankin Scale (mRS), National Hospital Seizure Severity Scale, Headache Impact Test and Patient Health Questionnaire for depression. RESULTS: There was a good correlation between physician and patient reported outcome measures. The Spearman's rank correlation coefficient between mRS and structured SIS Version 3 was -0.887 (p < 0.001); with unstructured SIS results, the correlation coefficient was -0.663 (p = 0.001). There was no statistically significant correlation between life worth and modified Rankin Scale: r = -0.3383 (p = 0.087). DISCUSSION: Our findings of a statistically significant correlation between mRS and SIS have not previously been reported in patients with this condition. These findings provide further information to inform patient and next of kin discussions regarding outcomes from decompressive hemicraniectomy in malignant MCA infarction

Chronic subdural haematoma: disseminating and implementing best practice

Peter Hutchinson is supported by a Research Professorship from the National Institute for Health Research (NIHR), the NIHR Cambridge Biomedical Research Centre, a European Union Seventh Framework Program grant (CENTER-TBI; grant no. 602150), and the Royal College of Surgeons of England

Survival with disability. Whose life is it, anyway?

Editor—We read with interest the editorial by Dr Lönnqvist entitled “Medical Research and the Ethics of Medical Treatments: Disability-free Survival”.1 The editorial refers to our study, RESCUEicp, that interrogated the effect of secondary decompressive craniectomy in traumatic brain injury (TBI) patients with refractory intracranial hypertension.2 The editorial states ‘the conclusion to draw is instead that, despite reducing overall mortality, surgery is not associated with any true long-term benefits in this setting; it only increases the number of patients in a vegetative state or suffering serious disability, and should therefore not be used’. We have major concerns about this statement with reference to our study, and with the wider premise that underpins the editorial, and we will address each of these in turn.The RESCUEicp and RESCUE-ASDH projects were funded by the National Institute for Health Research (NIHR; EME 09/800/16 and HTA 12/35/57 respectively)

Magnetic Resonance Imaging of the Codman Microsensor Transducer Used for Intraspinal Pressure Monitoring: Findings from the Injured Spinal Cord Pressure Evaluation study.

STUDY DESIGN: Laboratory and human study. OBJECTIVE: 1) To test the Codman Microsensor Transducer (CMT) in a cervical gel phantom. 2) To test the CMT inserted to monitor intraspinal pressure in a patient with spinal cord injury. SUMMARY OF BACKGROUND DATA: We recently introduced the technique of intraspinal pressure monitoring using the CMT to guide management of traumatic spinal cord injury [Werndle et al. Crit Care Med 2014;42:646]. This is analogous to intracranial pressure monitoring to guide management of patients with traumatic brain injury. It is unclear whether MRI of patients with spinal cord injury is safe with the intraspinal pressure CMT in situ. METHODS: We measured the heating produced by the CMT placed in a gel phantom in various configurations. A 3 T MRI system was used with the body transmit coil and the spine array receive coil. A CMT was then inserted subdurally at the injury site in a patient who had traumatic spinal cord injury and MRI was performed at 1.5 T. RESULTS: In the gel phantom, heating of up to 5 °C occurred with the transducer wire placed straight through the magnet bore. The heating was abolished when the CMT wire was coiled and passed away from the bore. We then tested the CMT in a patient with an American Spinal Injuries Association grade C cervical cord injury. The CMT wire was placed in the configuration that abolished heating in the gel phantom. Good quality T1 and T2 images of the cord were obtained without neurological deterioration. The transducer remained functional after the MRI. CONCLUSION: Our data suggest that the CMT is MR conditional when used in the spinal configuration in humans. Data from a large patient group are required to confirm these findings. LEVEL OF EVIDENCE: N/A

UK Chiari 1 Study: protocol for a prospective, observational, multicentre study

INTRODUCTION: Chiari 1 malformation (CM1) is a structural abnormality of the hindbrain characterised by the descent of the cerebellar tonsils through the foramen magnum. The management of patients with CM1 remains contentious since there are currently no UK or international guidelines for clinicians. We therefore propose a collaborative, prospective, multicentre study on the investigation, management and outcome of CM1 in the UK: the UK Chiari 1 Study (UKC1S). Our primary objective is to determine the health-related quality of life (HRQoL) in patients with a new diagnosis of CM1 managed either conservatively or surgically at 12 months of follow-up. We also aim to: (A) determine HRQoL 12 months following surgery; (B) measure complications 12 months following surgery; (C) determine the natural history of patients with CM1 treated conservatively without surgery; (D) determine the radiological correlates of presenting symptoms, signs and outcomes; and (E) determine the scope and variation within UK practice in referral patterns, patient pathways, investigations and surgical decisions. METHODS AND ANALYSIS: The UKC1S will be a prospective, multicentre and observational study that will follow the British Neurosurgical Trainee Research Collaborative model of collaborative research. Patients will be recruited after attending their first neurosurgical outpatient clinic appointment. Follow-up data will be collected from all patients at 12 months from baseline regardless of whether they are treated surgically or not. A further 12-month postoperative follow-up timepoint will be added for patients treated with decompressive surgery. The study is expected to last three years. ETHICS AND DISSEMINATION: The UKC1S received a favourable ethical opinion from the East Midlands Leicester South Research Ethics Committee (REC reference: 20/EM/0053; IRAS 269739) and the Health Research Authority. The results of the study will be published in peer-reviewed medical journals, presented at scientific conferences, shared with collaborating sites and shared with participant patients if they so wish

Isolated oculomotor nerve palsy in patients with mild head injury

Isolated oculomotor nerve palsy following head injury is uncommon. It can only be diagnosed with confidence if it is known to have developed immediately following trauma and if adequate investigations exclude secondary causes. The recovery is only partial and this has repercussion on patients' quality of life

The reporting of study and population characteristics in degenerative cervical myelopathy: A systematic review

OBJECT: Degenerative cervical myelopathy [DCM] is a disabling and increasingly prevalent condition. Variable reporting in interventional trials of study design and sample characteristics limits the interpretation of pooled outcomes. This is pertinent in DCM where baseline characteristics are known to influence outcome. The present study aims to assess the reporting of the study design and baseline characteristics in DCM as the premise for the development of a standardised reporting set. METHODS: A systematic review of MEDLINE and EMBASE databases, registered with PROSPERO (CRD42015025497) was conducted in accordance with PRISMA guidelines. Full text articles in English, with >50 patients (prospective) or >200 patients (retrospective), reporting outcomes of DCM were deemed to be eligible. RESULTS: A total of 108 studies involving 23,876 patients, conducted world-wide, were identified. 33 (31%) specified a clear primary objective. Study populations often included radiculopathy (51, 47%) but excluded patients who had undergone previous surgery (42, 39%). Diagnositic criteria for myelopathy were often uncertain; MRI assessment was specified in only 67 (62%) of studies. Patient comorbidities were referenced by 37 (34%) studies. Symptom duration was reported by 46 (43%) studies. Multivariate analysis was used to control for baseline characteristics in 33 (31%) of studies. CONCLUSIONS: The reporting of study design and sample characteristics is variable. The development of a consensus minimum dataset for (CODE-DCM) will facilitate future research synthesis in the future.Research in the senior author’s laboratory is supported by a core support grant from the Wellcome Trust and MRC to the Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute. MRNK is supported by a NIHR Clinician Scientist Award (CS-2015-15-023). PJAH holds a NIHR research professorship and is supported by the NIHR Cambridge Biomedical Research Centre. MGF acknowledges support from the Halbert Chair in Neural Repair and Regeneration and the Dezwirek Foundation

Neurotrauma clinicians' perspectives on the contextual challenges associated with long-term follow-up following traumatic brain injury in low-income and middle-income countries: a qualitative study protocol.

INTRODUCTION: Traumatic brain injury (TBI) is a global public health concern; however, low/middle-income countries (LMICs) face the greatest burden. The WHO recognises the significant differences between patient outcomes following injuries in high-income countries versus those in LMICs. Outcome data are not reliably recorded in LMICs and despite improved injury surveillance data, data on disability and long-term functional outcomes remain poorly recorded. Therefore, the full picture of outcome post-TBI in LMICs is largely unknown. METHODS AND ANALYSIS: This is a cross-sectional pragmatic qualitative study using individual semistructured interviews with clinicians who have experience of neurotrauma in LMICs. The aim of this study is to understand the contextual challenges associated with long-term follow-up of patients following TBI in LMICs. For the purpose of the study, we define 'long-term' as any data collected following discharge from hospital. We aim to conduct individual semistructured interviews with 24-48 neurosurgeons, beginning February 2020. Interviews will be recorded and transcribed verbatim. A reflexive thematic analysis will be conducted supported by NVivo software. ETHICS AND DISSEMINATION: The University of Cambridge Psychology Research Ethics Committee approved this study in February 2020. Ethical issues within this study include consent, confidentiality and anonymity, and data protection. Participants will provide informed consent and their contributions will be kept confidential. Participants will be free to withdraw at any time without penalty; however, their interview data can only be withdrawn up to 1 week after data collection. Findings generated from the study will be shared with relevant stakeholders such as the World Federation of Neurosurgical Societies and disseminated in conference presentations and journal publications