Neurosurgery

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 | UTC

Study 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):

Connolly SJ, Sharma M, Cohen AT, et al. (2024). Andexanet for Factor Xa Inhibitor-Associated Acute Intracerebral Hemorrhage. New England Journal of Medicine, 390(19), 1745-1755. DOI: 10.1056/NEJMoa2313040.

RCT: Early minimally invasive surgery may improve outcomes in selected patients with intracerebral hemorrhage – N Engl J Med

25 May, 2024 | 18:58h | UTC

Study 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):

Pradilla, G. et al. (2024). Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. N Engl J Med, 390(14), 1277-1289. DOI: 10.1056/NEJMoa2308440.

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 | UTC

Study 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):

Holmes, J. F. et al. (2024). PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study. The Lancet Child & Adolescent Health, May 2024, https://doi.org/10.1016/S2352-4642(24)00029-4.

RCT – 2ry Analysis | Elevated intracranial bleeding risk with low-dose aspirin in older adults

27 Jul, 2023 | 13:09h | UTC

Low-Dose Aspirin and the Risk of Stroke and Intracerebral Bleeding in Healthy Older People: Secondary Analysis of a Randomized Clinical Trial – JAMA Network Open

See 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 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: Association of Aspirin Use for Primary Prevention with Cardiovascular Events and Bleeding Events

Meta-Analysis: Efficacy and Safety of Aspirin for Primary Prevention of Cardiovascular Events

Aspirin for primary prevention of cardiovascular disease: a meta-analysis with a particular focus on subgroups – BMC Medicine

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 | UTC

IQ 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 | UTC

Subarachnoid hemorrhage: ED presentation, evaluation, and management – emDocs

AHA/ASA Guideline for the management of patients with aneurysmal subarachnoid hemorrhage

Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management – National Institute for Health and Care Excellence

Consensus Recommendations: Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities.

Intracranial Pressure Monitoring and Management in Aneurysmal Subarachnoid Hemorrhage – Neurocritical Care

Cohort Study | Significant traumatic brain injury rates in e-scooter accidents in France

11 Jul, 2023 | 13:36h | UTC

Comparison of Injuries Associated With Electric Scooters, Motorbikes, and Bicycles in France, 2019-2022 – JAMA Network Open

See 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 | UTC

Dexamethasone 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

News Release: International expert panel revises management of concussion in sport for optimal care of athletes at all levels of participation – BMJ

RCT | Care bundle with intensive blood pressure control improves outcomes in acute cerebral hemorrhage

30 May, 2023 | 12:04h | UTC

The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial – The Lancet

News Release: Tens of thousands of lives a year could be saved by new treatment protocol for brain hemorrhage – George Institute for Global Health

RCT | Preliminary evidence for right median nerve stimulation in awakening from acute traumatic coma

30 May, 2023 | 11:36h | UTC

Acute traumatic coma awakening by right median nerve electrical stimulation: a randomised controlled trial – Intensive Care Medicine

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/nvLl9A84oD

Refers 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 | UTC

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association – Stroke

Top 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

Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke: updated consensus guideline recommendations by the Neuroprotective Therapy Consensus Review (NTCR) group – British Journal of Anaesthesia

Guideline | Assessment and early management of head injury

23 May, 2023 | 13:11h | UTC

Head injury: assessment and early management – NICE

Commentary: NICE head injury guidelines 2023: Now who do we scan? – St Emilyn’s

News Release: International study recommends replacing skull section after treatment for a brain bleed – University of Cambridge

Commentary on Twitter

Presented at #AANS2023: In an international trial involving 450 patients with acute subdural hematoma, craniotomy (replacing bone flap) and decompressive craniectomy (removing bone flap) yielded similar disability results at 12 months. https://t.co/KoNebwQIsi #neurosurgery pic.twitter.com/t9E9YZeHyq

— NEJM (@NEJM) April 23, 2023

M-A | Pain management interventions for the treatment of chronic low back pain

2 May, 2023 | 13:26h | UTC

Pain Management Interventions for the Treatment of Chronic Low Back Pain: A Systematic Review and Meta-Analysis – The Clinical Journal of Pain

Randomized Controlled Trial: Mixed results with Andexanet Alfa for Factor Xa inhibitor-associated acute intracerebral hemorrhage – N Engl J Med

RCT: Early minimally invasive surgery may improve outcomes in selected patients with intracerebral hemorrhage – N Engl J Med

Prospective Validation Study: High accuracy of PECARN rules in reducing unnecessary CT scans in pediatric blunt trauma – Lancet Child Adolesc Health

RCT – 2ry Analysis | Elevated intracranial bleeding risk with low-dose aspirin in older adults

Prospective Study | Intelligence likely remains intact after pediatric concussion

Subarachnoid hemorrhage | ED presentation, evaluation, and management

Cohort Study | Significant traumatic brain injury rates in e-scooter accidents in France

Review | Respiratory challenges and ventilatory management in different types of acute brain-injured patients

Editorial | How to become a good surgeon

Review | Intracranial pressure monitoring and management in aneurysmal subarachnoid hemorrhage

RCT | Use of lumbar drains improves 6-month outcomes in patients with aneurysmal subarachnoid hemorrhage

RCT | In chronic subdural hematoma, dexamethasone fails to match surgery for functional outcomes

Guidelines for the management of trigeminal neuralgia

M-A | Mechanical ventilation in patients with acute brain injury

Consensus Statement | Concussion in sport

RCT | Care bundle with intensive blood pressure control improves outcomes in acute cerebral hemorrhage

RCT | Preliminary evidence for right median nerve stimulation in awakening from acute traumatic coma

AHA/ASA Guideline for the management of patients with aneurysmal subarachnoid hemorrhage

Guideline | Targeted temperature management in intracerebral, subarachnoid hemorrhage and acute ischemic stroke

Guideline | Assessment and early management of head injury

Neurosurgical interventions for cerebral metastases of solid tumors

Review | Early switch to oral antimicrobials in brain abscess

ESTES recommendation on thoracolumbar spine fractures

RCT | Craniotomy and decompressive craniectomy yield comparable outcomes in acute subdural hematoma

M-A | Pain management interventions for the treatment of chronic low back pain

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