Archivos de la categoría Neurotraumatología

Predicting Recurrence after Chronic Subdural Haematoma Drainage

Recurrence of chronic subdural haematomas (CSDHs) after surgical drainage is a significant problem with rates up to 20%. This study focuses on determining factors predictive of haematoma recurrence and presents a scoring system stratifying recurrence risk for individual patients. Methods : Between the years 2005 and 2009, 331 consecutive patients with CSDHs treated with surgery were included in this study. Univariate and multivariate analyses were performed searching for risk factors of increased post-operative haematoma volume and haematoma recurrence requiring repeat drainage. Results: We found a 12% reoperation rate. CSDH septation (seen on computed tomogram scan) was found to be an independent risk factor for recurrence requiring reoperation (p=0.04). Larger post-operative subdural haematoma volume was also significantly associated with requiring a second drainage procedure (p<0.001). Independent risk factors of larger post-operative haematoma volume included septations within a CSDH (p<0.01), increased pre-operative haematoma volume (p<0.01), and a greater amount of parenchymal atrophy (p=0.04). A simple scoring system for quantifying recurrence risk was created and validated based on patient age (< or ≥80 years), haematoma volume (< or ≥160cc), and presence of septations within the subdural collection (yes or no). Conclusion: Septations within CSDHs are associated with larger post-operative residual haematoma collections requiring repeat drainage. When septations are clearly visible within a CSDH, craniotomy might be more suitable as a primary procedure as it allows greater access to a septated subdural collection. Our proposed scoring system combining haematoma volume, age, and presence of septations might be useful in identifying patients at higher risk for recurrence1

  1. Jack A, O’Kelly C, McDougall C, Max Findlay J. Predicting Recurrence after Chronic Subdural Haematoma Drainage. Can J Neurol Sci. 2015 Jan 5:1-6. [Epub ahead of print] PubMed PMID: 25557536. []

The SYNAPSE Trial has failed

Progesterone is an endogenous steroid hormone involved in the menstrual cycle, pregnancy, and embryogenesis of humans and other species.

It belongs to a group of steroid hormones called the progestogens, and is the major progestogen in the body. Progesterone is also a crucial metabolic intermediate in the production other endogenous steroids, including the sex hormones and the corticosteroids, and plays an important role in brain function as a neurosteroid.

Progesterone has been associated with robust positive effects in animal models of traumatic brain injury (TBI) and with clinical benefits in twophase 2 randomized controlled trials. Skolnick et al, investigated the efficacy and safety of progesterone in a large, prospective, phase 3 randomized controlled trial.

A multinational placebo controlled study, in which 1195 patients, 16 to 70 years of age, with severe traumatic brain injury TBI (Glasgow Coma Scale score, ≤8 (on a scale of 3 to 15, with lower scores indicating a reduced level of consciousness and at least one reactive pupil) wererandomly assigned to receive progesterone or placebo. Dosing began within 8 hours after injury and continued for 120 hours. The primary efficacy end point was the Glasgow Outcome Scale score at 6 months after the injury.

Proportional-odds analysis with covariate adjustment showed no treatment effect of progesterone as compared with placebo (odds ratio, 0.96;confidence interval, 0.77 to 1.18). The proportion of patients with a favorable outcome on the Glasgow Outcome Scale (good recovery or moderate disability) was 50.4% with progesterone, as compared with 50.5% with placebo. Mortality was similar in the two groups. No relevantsafety differences were noted between progesterone and placebo.

Primary and secondary efficacy analyses showed no clinical benefit of progesterone in patients with severe TBI. These data stand in contrast to the robust preclinical data and results of early single-center trials that provided the impetus to initiate phase 3 trials. (Funded by BHR Pharma; SYNAPSE ClinicalTrials.gov number, NCT01143064 .) 1).

1) Skolnick BE, Maas AI, Narayan RK, van der Hoop RG, MacAllister T, Ward JD, Nelson NR, Stocchetti N; the SYNAPSE Trial Investigators. A Clinical Trial of Progesterone for Severe Traumatic Brain Injury. N Engl J Med. 2014 Dec 10. [Epub ahead of print] PubMed PMID: 25493978.

Moderate elevations in international normalized ratio should not lead to delays in neurosurgical intervention in patients with traumatic brain injury

Intracranial procedures are often deferred until an international normalized ratio (INR) of less than 1.4 is achieved. There is no evidence that a moderately elevated INR is associated with increased risk of bleeding in neurosurgical intervention (NI). Thromboelastography (TEG) provides a functional assessment of clotting and has been shown to better predict clinically relevant coagulopathy compared with INR.

Traumatic brain injury (TBI) patients with an admission INR of greater than 1.4 had a longer time to NI. The use of plasma transfusion to decrease the INR may have contributed to this delay. A moderately elevated INR was not associated with coagulopathy based on TEG. Routine plasma transfusion to correct a moderately elevated INR before NI should be reexamined

Rowell SE, Barbosa RR, Lennox TC, Fair KA, Rao AJ, Underwood SJ, Schreiber MA. Moderate elevations in international normalized ratio should not lead to delays in neurosurgical intervention in patients with traumatic brain injury. J Trauma Acute Care Surg. 2014 Dec;77(6):846-851. PubMed PMID: 25423533.

XVI Simposium Internacional de Neuromonitorización y Tratamiento del Paciente Neurocrítico

XVI Simposium Internacional de Neuromonitorización y Tratamiento del Paciente Neurocrítico

Barcelona, 18 – 22 de noviembre de 2014

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Hoy cursos precongreso:

ACTUALIZACIONES EN LA FISIOPATOLOGÍA Y TRATAMIENTO DEL TRAUMATISMO CRANEOENCEFÁLICO
MONITORIZACIÓN DE LA AUTORREGULACIÓN CEREBRAL. FUNDAMENTOS FISIOLÓGICOS DE IMPORTANCIA CLÍNICA
HEMORRAGIA SUBARACNOIDEA ANEURISMÁTICA. ACTUALIZACIÓN EN LA FISIOPATOLOGÍA, MONITORIZACIÓN Y TRATAMIENTO 
MONITORIZACIÓN DE LA OXIGENACIÓN CEREBRAL EN EL PACIENTE NEUROCRÍTICO. FUNDAMENTOS, MONITORIZACIÓN Y APLICACIONES PRÁCTICAS
CONTROVERSIAS EN LA FISIOPATOLOGÍA, NEUROMONITORIZACIÓN Y TRATAMIENTO DEL PACIENTE NEUROCRÍTICO

Today: Controversies in Neurotrauma

controvnov7This course is designed to provide participants with a unique opportunity to advance their knowledge and surgical skills in brain trauma and spinal cord trauma through didactic lectures and case-based discussions with renowned neurotrauma thought leaders.

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