Enlighten-Research publications by members of the University of Glasgow http://eprints.gla.ac.uk Minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label phase 3 trial with blinded endpoint

EVERE TRAUMATIC BRAIN INJURY (TBI) is common in patients with major trauma and typically involves young adult men. 1 Despite current management strategies, patients with severe TBI have a high mortality rate (31%-49%) and a large number of survivors have persistent severe neurological disability. 1-4 There are 80000 to 90 000 were cases of survivors with long-term disability after head injury annually in the United States. 5 The mean lifetime cost of each TBI survivor with severe disability from TBI exceeds US $2 million. 6 After initial head trauma, secondary brain injury may occur due to hypoxia, hypotension, or elevated intracranial pressure (ICP) and is associated with a worse neurological outcome. 3,7 Patients with hypotension after severe TBI have twice the mortality rate of normotensive patients. 5 Therefore, aggressive resuscitation with intravenous fluids is recommended in current guidelines for the management of patients with severe TBI. 8 Treatment of increased ICP in patients with TBI is also likely to improve outcomes. 3

Background and Purpose-The purpose of this study was to analyze whether treating ruptured intracranial aneurysms within 24 hours of subarachnoid hemorrhage improves clinical outcome. Methods-An 11-year database of consecutive ruptured intracranial aneurysms treated with endovascular coiling or craniotomy and clipping was analyzed. Outcome was measured by the modified Rankin Scale at 6 months. Our policy is to treat all cases within 24 hours of subarachnoid hemorrhage. Treatment delays are due to nonclinical logistical factors. Results-Two hundred thirty cases were coiled or clipped within 24 hours of subarachnoid hemorrhage and 229 at Ͼ24 hours.No difference in age, gender, smoking, family history of subarachnoid hemorrhage, aneurysm size, or aneurysm location was found between the groups. Poor World Federation of Neurological Surgeons clinical grade patients were overrepresented in the ultra-early group. Increasing age and higher World Federation of Neurological Surgeons clinical grade were predictors of poor outcome. Eight point zero percent of cases treated within 24 hours of subarachnoid hemorrhage (ultra-early) were dependent or dead at 6 months compared with 14.4% of those treated at Ͼ24 hours (delayed), a 44.0% relative risk reduction and a 6.4% absolute risk reduction (

The major risk of rebleeding after SAH is present within the first 6 to 12 hours. This risk of ultra-early rebleeding is highest for patients with poor grades. Securing ruptured aneurysms by surgery or coil placement on an emergency basis for all patients with SAH has a strong rational argument.

There is no uniformly accepted protocol for the radiological assessment of the cervical spine in critically ill trauma patients. The Alfred Trauma Centre receives about 40% of Victorian patients with major trauma. A protocol was developed for cervical spine evaluation, comprising three plain X-rays and a swimmer's view added when necessary to visualize C7-T1, CT and/or MRI for abnormal regions, and functional (flexion/extension) X-rays to exclude cervical spine instability due to soft tissue trauma. Functional X-rays were performed “actively” in conscious patients and “passively” in unconscious patients. One hundred consecutive patients were prospectively evaluated and 91 survived to complete data collection. Six (6.6%) had unstable cervical spine injuries—five detected with plain X-rays and one (1.1%) detected only with passive functional X-rays. Static cervical X-rays cost $93.00 per patient. Functional cervical X-rays added $42.00 per patient and were uncomplicated. Collar complications were common when collars remained on for more than 72 hours. This low detection rate is clinically important because of the enormous potential social and economic costs of missed unstable cervical spine fractures.