Neurosurgery
Phase 2b Trial: Nicardipine Implants Show Promise in Reducing Vasospasm After Aneurysmal Subarachnoid Hemorrhage – JAMA Neurology
25 Aug, 2024 | 11:29h | UTCStudy Design and Population: This single-masked, multicenter, randomized clinical trial involved 41 patients with World Federation of Neurological Surgeons grade 3 or 4 aneurysmal subarachnoid hemorrhage (aSAH) from six neurovascular centers in Germany and Austria. The patients were randomized to either receive localized nicardipine release implants during microsurgical aneurysm repair plus standard care or standard care alone.
Main Findings: The incidence of moderate to severe angiographic vasospasm (aVS) between days 7 and 9 after aSAH was significantly lower in the implant group (20%) compared to the control group (58%; P = .02). Additionally, fewer patients in the implant group required vasospasm rescue therapy (10% vs. 58%; P = .002). However, at 52 weeks, no significant difference was observed in favorable outcomes between the groups (84% in the implant group vs. 67% in the control group; P = .27).
Implications for Practice: Nicardipine implants show promise in reducing vasospasm-related complications following aSAH, suggesting a potential benefit for early postoperative management. However, their impact on long-term clinical outcomes requires further investigation in larger phase 3 trials to determine the overall benefit and cost-effectiveness of this intervention.
Non-Inferiority Trial: Burr-Hole Drainage Without Irrigation Results in Higher Reoperation Rate in Chronic Subdural Hematoma – The Lancet
18 Aug, 2024 | 18:17h | UTCStudy Design and Population: This Finnish, nationwide, multicentre, randomised, controlled non-inferiority trial (FINISH) evaluated whether subdural irrigation during burr-hole drainage for chronic subdural haematoma could be omitted without compromising outcomes. The trial enrolled 589 adults (165 women, 424 men) requiring burr-hole drainage, randomly assigned to receive drainage with or without irrigation.
Main Findings: The study found a 6.0 percentage point higher reoperation rate within 6 months in the non-irrigation group (18.3%) compared to the irrigation group (12.6%). There were no significant differences in secondary outcomes, including the proportion of patients with an unfavorable functional outcome (13.1% vs. 12.6%) or mortality (6.1% vs. 7.1%). Adverse events were comparable between the groups.
Implications for Practice: The trial results suggest that omitting subdural irrigation during burr-hole drainage increases the risk of reoperation, without improving functional outcomes or reducing mortality. The findings support the continued use of subdural irrigation in this procedure.
Randomized Controlled Trial: Mixed results with Andexanet Alfa for Factor Xa inhibitor-associated acute intracerebral hemorrhage – N Engl J Med
27 May, 2024 | 20:26h | UTCStudy Design and Population: This randomized controlled trial involved 530 patients with acute intracerebral hemorrhage who had taken factor Xa inhibitors within 15 hours before the event. They were randomly assigned to receive either andexanet alfa or usual care.
Main Findings: Hemostatic efficacy was achieved in 67% of patients receiving andexanet compared to 53.1% receiving usual care. Andexanet significantly reduced anti-factor Xa activity by 94.5%, compared to 26.9% with usual care. However, thrombotic events were more frequent in the andexanet group, including ischemic stroke.
Implications for Practice: Andexanet alfa is effective in controlling hematoma expansion in patients with factor Xa inhibitor-associated intracerebral hemorrhage but has an increased risk of thrombotic events. Further research is needed to balance efficacy and safety.
Reference (link to abstract – $ for full-text):
RCT: Early minimally invasive surgery may improve outcomes in selected patients with intracerebral hemorrhage – N Engl J Med
25 May, 2024 | 18:58h | UTCStudy Design and Population: This multicenter randomized clinical trial investigated the efficacy of early minimally invasive surgical removal of intracerebral hemorrhage compared to medical management alone. The trial enrolled 300 patients within 24 hours of symptom onset, who had either lobar or anterior basal ganglia hemorrhages, with hematoma volumes ranging from 30 to 80 ml. An adaptation rule was applied partway through the trial, resulting in the exclusive enrollment of patients with lobar hemorrhages after 175 patients were initially enrolled.
Main Findings: Patients in the surgery group achieved a significantly higher mean score on the utility-weighted modified Rankin scale at 180 days (0.458) compared to the control group (0.374), with a difference of 0.084 and a posterior probability of superiority of 0.981. Notably, the benefit of surgery was pronounced among patients with lobar hemorrhages (mean difference 0.127), whereas no benefit was observed in patients with anterior basal ganglia hemorrhages. Additionally, the surgery group experienced a lower 30-day mortality rate (9.3%) compared to the control group (18.0%).
Implications for Practice: The results suggest that early minimally invasive surgery for intracerebral hemorrhage, particularly for lobar hemorrhages, offers significant functional benefits over medical management alone. These findings support the selective use of this surgical approach in clinical settings, potentially leading to improved patient outcomes. Further studies could explore the differential impact of hemorrhage location on surgical outcomes to refine treatment guidelines.
Reference (link to abstract – $ for full-text):
Prospective Validation Study: High accuracy of PECARN rules in reducing unnecessary CT scans in pediatric blunt trauma – Lancet Child Adolesc Health
5 May, 2024 | 15:08h | UTCStudy Design and Population:
This multicenter prospective validation study tested the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules aimed at reducing unnecessary CT scans for children presenting with blunt abdominal or minor head trauma. Over a nearly five-year period, children and adolescents under 18 from six U.S. emergency departments in cities including Sacramento, Dallas, and Los Angeles were enrolled. Exclusion criteria included pregnancy, pre-existing neurological disorders, penetrating trauma, injuries older than 24 hours, prior CT or MRI scans, or suspicion of non-accidental trauma.
Main Findings:
A total of 7,542 children with blunt abdominal trauma and 19,999 with minor head trauma were enrolled. The intra-abdominal injury rule demonstrated a sensitivity and negative predictive value (NPV) of 100%, confirming its reliability in detecting injuries requiring acute intervention. For head traumas, the sensitivity varied slightly with age; 100% for children under 2 years and 98.8% for those aged 2 years and older, with an NPV of 100% in both groups. Only two cases in the older cohort were misclassified, neither requiring neurosurgery.
Implications for Practice:
The validation of PECARN rules with high sensitivity and NPV supports their use as a safe guideline to minimize unnecessary CT scans in pediatric trauma cases, thereby promoting efficient use of resources and reducing exposure to radiation in children. These results suggest that implementation of these rules should be considered in emergency pediatric care to improve outcomes and healthcare efficiency.
Reference (link to abstract – $ for full-text):
RCT – 2ry Analysis | Elevated intracranial bleeding risk with low-dose aspirin in older adults
27 Jul, 2023 | 13:09h | UTCSee also: Visual Abstract
News Release: Low dose aspirin won’t help some older adults trying to avoid a stroke: study – Monash University
Commentary: Daily aspirin doesn’t prevent strokes in older, healthy people after all – The Conversation
Original Study: Randomized Trial: Effect of Aspirin on All-Cause Mortality in the Healthy Elderly
Related Guideline: USPSTF Recommendation Statement: Aspirin Use to Prevent Cardiovascular Disease.
Related Randomized Trials:
Randomized Trial: Aspirin for Primary Prevention of Cardiovascular Disease
Randomized Trial: Effects of Aspirin for Primary Prevention in Persons with Diabetes
Related Meta-Analysis:
Meta-Analysis: Efficacy and Safety of Aspirin for Primary Prevention of Cardiovascular Events
Related Opinions:
Aspirin for Primary Prevention: Is This the End of the Road?
Evidence evolving on aspirin as prevention – ACP Internist
#347 USPSTF Update: Aspirin for Primary Prevention of CVD – The Curbsiders
Prospective Study | Intelligence likely remains intact after pediatric concussion
20 Jul, 2023 | 11:06h | UTCIQ After Pediatric Concussion – Pediatrics (free for a limited period)
Commentaries:
IQ After Pediatric Concussion: Clinical Considerations – Pediatrics
No Evidence Seen for Differences in IQ After Pediatric Concussion – HealthDay
Concussions do not affect IQ in children, study finds – News Medical
Subarachnoid hemorrhage | ED presentation, evaluation, and management
11 Jul, 2023 | 13:49h | UTCSubarachnoid hemorrhage: ED presentation, evaluation, and management – emDocs
Related:
AHA/ASA Guideline for the management of patients with aneurysmal subarachnoid hemorrhage
Cohort Study | Significant traumatic brain injury rates in e-scooter accidents in France
11 Jul, 2023 | 13:36h | UTC
Review | Respiratory challenges and ventilatory management in different types of acute brain-injured patients
3 Jul, 2023 | 14:17h | UTC
Editorial | How to become a good surgeon
22 Jun, 2023 | 15:12h | UTCHow to become a good surgeon – Advances in Ophthalmology Practice and Research
Review | Intracranial pressure monitoring and management in aneurysmal subarachnoid hemorrhage
22 Jun, 2023 | 15:02h | UTC
RCT | Use of lumbar drains improves 6-month outcomes in patients with aneurysmal subarachnoid hemorrhage
20 Jun, 2023 | 12:55h | UTCSee also: Visual Abstract
Commentary on Twitter
In this trial, among patients with aneurysmal subarachnoid hemorrhage, lumbar drainage improved clinical neurological outcomes at 6 months. https://t.co/SZjuQoGoku pic.twitter.com/szKcZaPL9K
— JAMA Neurology (@JAMANeuro) June 18, 2023
RCT | In chronic subdural hematoma, dexamethasone fails to match surgery for functional outcomes
20 Jun, 2023 | 12:53h | UTCDexamethasone versus Surgery for Chronic Subdural Hematoma – New England Journal of Medicine (link to abstract – $ for full-text)
Commentary: Dexamethasone Compared to Burr-Hole Drainage for Chronic Subdural Hematoma – HealthDay
Guidelines for the management of trigeminal neuralgia
20 Jun, 2023 | 12:43h | UTCGuidelines for the management of trigeminal neuralgia – Cleveland Clinic Journal of Medicine
M-A | Mechanical ventilation in patients with acute brain injury
16 Jun, 2023 | 14:03h | UTC
Consensus Statement | Concussion in sport
15 Jun, 2023 | 15:14h | UTC
RCT | Care bundle with intensive blood pressure control improves outcomes in acute cerebral hemorrhage
30 May, 2023 | 12:04h | UTC
RCT | Preliminary evidence for right median nerve stimulation in awakening from acute traumatic coma
30 May, 2023 | 11:36h | UTC
Commentary on Twitter
? Unlocking consciousness: important data on @yourICM but results should be replicated ideally by multicentric trial w blind intervention + including detailed data on WLSM as long-term outcome by validated metric.
?️ https://t.co/nvLl9A84oDRefers to
?️ https://t.co/VifPF3wTvI pic.twitter.com/0Sqpu56Mov— Intensive Care Medicine (@yourICM) May 22, 2023
AHA/ASA Guideline for the management of patients with aneurysmal subarachnoid hemorrhage
29 May, 2023 | 11:16h | UTCTop Things to Know: 2023 Aneurysmal Subarachnoid Hemorrhage Guideline – American Heart Association
Commentary on Twitter
2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association https://t.co/IHZRkTR25t@American_Heart @American_Stroke @AHAScience @BrianHoh1 @drdangayach @CPDerdeyn pic.twitter.com/I2JdXnHuXp
— Stroke AHA/ASA (@StrokeAHA_ASA) May 23, 2023
Guideline | Targeted temperature management in intracerebral, subarachnoid hemorrhage and acute ischemic stroke
29 May, 2023 | 10:48h | UTC
Guideline | Assessment and early management of head injury
23 May, 2023 | 13:11h | UTCHead injury: assessment and early management – NICE
Commentary: NICE head injury guidelines 2023: Now who do we scan? – St Emilyn’s
Neurosurgical interventions for cerebral metastases of solid tumors
11 May, 2023 | 11:48h | UTC
Review | Early switch to oral antimicrobials in brain abscess
10 May, 2023 | 15:55h | UTC
ESTES recommendation on thoracolumbar spine fractures
10 May, 2023 | 15:40h | UTC