Current Perspectives in the Surgical Treatment of Severe Traumatic Brain Injury

Giammattei, Lorenzo; Messerer, Mahmoud; Cherian, Iype; Starnoni, Daniele; Maduri, Rodolfo; Kasper, Ekkehard M.; Daniel, Roy Thomas

doi:10.1016/j.wneu.2018.05.176

Cited by 20 publications

(18 citation statements)

References 43 publications

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“…TBI causes primary mechanical injury of neuron cells and initiates secondary damage that occur after the primary damage. Many investigations indicated that secondary damage result in neuronal apoptosis is the main reason of poor outcome after TBI which is progressive from hours to days . Many pathological process were reported to be related to the neuronal apoptosis in the secondary damage .…”

Section: Introductionmentioning

confidence: 99%

Alpha lipoic acid inhibits oxidative stress‐induced apoptosis by modulating of Nrf2 signalling pathway after traumatic brain injury

Xia

Zhai

Wang

et al. 2019

J Cellular Molecular Medi

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Alpha lipoic acid (ALA) is a powerful antioxidant which has been widely used in the treatment of different system diseases, such as cardiovascular and cerebrovascular diseases. But, there are few studies that refer to protective effects and potential mechanisms on traumatic brain injury (TBI). This study was carried out to investigate the neuroprotective effect following TBI and illuminate the underlying mechanism. Weight drop‐injured model in rats was induced by weight‐drop. ALA was administrated via intraperitoneal injection after TBI. Neurologic scores were examined following several tests. Neurological score was performed to measure behavioural outcomes. Nissl staining and TUNEL were performed to evaluate the neuronal apoptosis. Western blotting was engaged to analyse the protein content of the Nuclear factor erythroid 2‐related factor 2 (Nrf2) and its downstream protein factors, including hemeoxygenase‐1 (HO‐1) and quinine oxidoreductase‐1 (NQO1). ALA treatment alleviated TBI‐induced neuron cell apoptosis and improved neurobehavioural function by up‐regulation of Nrf2 expression and its downstream protein factors after TBI. This study presents new perspective of the mechanisms responsible for the neuronal apoptosis of ALA, with possible involvement of Nrf2 pathway.

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Section: Introductionmentioning

confidence: 99%

Alpha lipoic acid inhibits oxidative stress‐induced apoptosis by modulating of Nrf2 signalling pathway after traumatic brain injury

Xia

Zhai

Wang

et al. 2019

J Cellular Molecular Medi

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“…The "standard" technique of opening the cisterns as commonly done in surgeries for ruptured aneurysms or skull base tumors is known to have a significant and immediate impact on brain swelling, thereby enabling a lax brain during these surgeries. This positive effect can further be enhanced in the postoperative phase by the placement of a cisternal drain, which is therefore conceptually different from EVD [12].…”

Section: Discussionmentioning

confidence: 99%

“…In the setting of severe TBI, there is almost always a significant amount of associated subarachnoid hemorrhage. It could be hypothesized that traumatic SAH could make the pressure rise within the cisternal compartment (by clogging the natural CSF drainage pathways), thus producing an outflow congestion or shift of fluid towards the brain [15] which then leads to brain swelling via the development of "CSF shift edema" [8,9,12]. By opening the basal cisterns and lamina terminalis, cisternostomy enables the catheter to drain both the cisternal and ventricular compartments, and this may therefore reverse this shift of fluid to the intraparenchymal compartment, thus alleviating brain swelling.…”

Section: Discussionmentioning

confidence: 99%

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Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

Giammattei¹,

Starnoni²,

Maduri³

et al. 2020

Acta Neurochir

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Objective To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI). Methods A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, "primary procedure" and "secondary procedure", was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO 2) values as well as the need for additional osmotherapy and CSF drainage. Results Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average postsurgical ICP values, higher PbO 2 values and required less osmotic treatments as compared with those treated with DC alone. Conclusion Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.

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“…The opening of basal cisterns (cisternostomy) has also been suggested as a surgical maneuver for managing posttraumatic brain swelling and elevated ICP [37]. However, this technique requires a microscope and instruments for microneurosurgery, which may limit its utility in resource-constrained settings.…”

Section: Limitations Of Current Evidence Basementioning

confidence: 99%

The Current Status of Decompressive Craniectomy in Traumatic Brain Injury

et al. 2018

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PurposeThis review describes the evidence base that has helped define the role of decompressive craniectomy (DC) in the management of patients with traumatic brain injury (TBI).Recent FindingsThe publication of two randomized trials (DECRA and RESCUEicp) has strengthened the evidence base. The DECRA trial showed that neuroprotective bifrontal DC for moderate intracranial hypertension is not helpful, whereas the RESCUEicp trial found that last-tier DC for severe and refractory intracranial hypertension can significantly reduce the mortality rate but is associated with a higher rate of disability. These findings have reopened the debate about (1) the indications for DC in various TBI subtypes, (2) alternative techniques (e.g., hinge craniotomy), (3) optimal time and material for cranial reconstruction, and (4) the role of shared decision-making in TBI care. Additionally, the role of primary DC when evacuating an acute subdural hematoma is currently undergoing evaluation in the context of the RESCUE-ASDH randomized trial.SummaryThis review provides an overview of the current evidence base, discusses its limitations, and presents a global perspective on the role of DC, as there is growing recognition that attention should also focus on low- and middle-income countries due to their much greater TBI burden.

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Current Perspectives in the Surgical Treatment of Severe Traumatic Brain Injury

Cited by 20 publications

References 43 publications

Alpha lipoic acid inhibits oxidative stress‐induced apoptosis by modulating of Nrf2 signalling pathway after traumatic brain injury

Alpha lipoic acid inhibits oxidative stress‐induced apoptosis by modulating of Nrf2 signalling pathway after traumatic brain injury

Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma

The Current Status of Decompressive Craniectomy in Traumatic Brain Injury

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