Jamie S. Ullman

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.

The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.

The future of neurosurgery: a white paper on the recruitment and retention of women in neurosurgery

PREFACE The leadership of Women in Neurosurgery (WINS) has been asked by the Board of Directors of the American Association of Neurological Surgeons (AANS) to compose a white paper on the recruitment and retention of female neurosurgical residents and practitioners. INTRODUCTION Neurosurgery must attract the best and the brightest. Women now constitute a larger percentage of medical school classes than men, representing approximately 60% of each graduating medical school class. Neurosurgery is facing a potential crisis in the US workforce pipeline, with the number of neurosurgeons in the US (per capita) decreasing. WOMEN IN THE NEUROSURGERY WORKFORCE The number of women entering neurosurgery training programs and the number of board-certified female neurosurgeons is not increasing. Personal anecdotes demonstrating gender inequity abound among female neurosurgeons at every level of training and career development. Gender inequity exists in neurosurgery training programs, in the neurosurgery workplace, and within organized neurosurgery. OBSTACLES The consistently low numbers of women in neurosurgery training programs and in the workplace results in a dearth of female role models for the mentoring of residents and junior faculty/practitioners. This lack of guidance contributes to perpetuation of barriers to women considering careers in neurosurgery, and to the lack of professional advancement experienced by women already in the field. There is ample evidence that mentors and role models play a critical role in the training and retention of women faculty within academic medicine. The absence of a critical mass of female neurosurgeons in academic medicine may serve as a deterrent to female medical students deciding whether or not to pursue careers in neurosurgery. There is limited exposure to neurosurgery during medical school. Medical students have concerns regarding gender inequities (acceptance into residency, salaries, promotion, and achieving leadership positions). Gender inequity in academic medicine is not unique to neurosurgery; nonetheless, promotion to full professor, to neurosurgery department chair, or to a national leadership position is exceedingly rare within neurosurgery. Bright, competent, committed female neurosurgeons exist in the workforce, yet they are not being promoted in numbers comparable to their male counterparts. No female neurosurgeon has ever been president of the AANS, Congress of Neurological Surgeons, or Society of Neurological Surgeons (SNS), or chair of the American Board of Neurological Surgery (ABNS). No female neurosurgeon has even been on the ABNS or the Neurological Surgery Residency Review Committee and, until this year, no more than 2 women have simultaneously been members of the SNS. Gender inequity serves as a barrier to the advancement of women within both academic and community-based neurosurgery. STRATEGIC APPROACH TO ADDRESS ISSUES IDENTIFIED To overcome the issues identified above, the authors recommend that the AANS join WINS in implementing a strategic plan, as follows: 1) Characterize the barriers. 2) Identify and eliminate discriminatory practices in the recruitment of medical students, in the training of residents, and in the hiring and advancement of neurosurgeons. 3) Promote women into leadership positions within organized neurosurgery. 4) Foster the development of female neurosurgeon role models by the training and promotion of competent, enthusiastic, female trainees and surgeons.

Decompressive Craniectomy for Severe Traumatic Brain Injury: A Systematic Review.

OBJECTIVE Systematic review of the literature to evaluate the role of decompressive craniectomy (DC) after severe traumatic brain injury (TBI), comparing the first major randomized clinical trial on this topic (DECRA) with subsequent literature. METHODS A systematic literature search was performed from 2011 to 2015. Citations were selected using the following inclusion criteria: closed severe TBI and DC. Exclusion criteria included most patients ≤18 years old, ≤20 participants, review articles, DC for reasons other than TBI, or surgical procedures other than DC. Primary outcomes included mortality and Glasgow Outcome Scale (GOS) at discharge, 6 months, and 1 year after injury. Assessment of risk of bias of the randomized controlled trials was also performed. RESULTS Only 12 of 5528 articles satisfied the eligibility criteria; of these studies, 3 were randomized controlled trials. DC in specific populations does not offer GOS or mortality advantages compared with medical treatment; on the other hand, when DC with open dural flap was compared with an alternative means of decompression, e.g., DC with multiple dural stabs, the latter showed significant advantage in mortality and GOS. Nonrandomized studies showed decreased mortality and increased GOS in patients aged ≤50 years when DC was performed <5 hours after TBI and with Glasgow Coma Scale score >5. CONCLUSIONS Our study underscores the importance of continued international prospective data collection for assessing types of surgical interventions in addition to DC and their timing in patients who have severe TBI. In addition, in geographic areas with limited access to advanced medical treatment for severe TBI, DC is of benefit when performed <5 hours after injury in younger patients with Glasgow Coma Scale >5.

In Reply: Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition

To the Editor: We thank Drs Picetti, Iaccarino, and Servadei for their thoughtful comments1 in relation to the recently published Guidelines for theManagement of Severe Traumatic Brain Injury, Fourth Edition.2 We share their distress and disappointment with the gaps that exist in current evidence for important topics. It is our great hope that the fourth edition guidelines will inspire investigators to complete high-quality studies that will fill these gaps. We also fully agree with the Parma group1 that published guidelines should not be viewed as “formally correct.” The Guidelines should serve as a starting point for individualized patient care protocols, integrating broad information specific to patient characteristics. The science of guidelines and making evidence-based recommendations has evolved substantially since the first edition of the Brain Trauma Foundation’s Guidelines for the Management of Severe Traumatic Brain Injury3—the first published guidelines produced by any surgical specialty. Indeed, much has changed even since the publication of the previous, third edition in 2007.4 The Institute of Medicine’s “Clinical Practice Guidelines We Can Trust” (2011)5 has played a particularly important role in setting the modern standard for high-quality guidelines documents. Our authorship group was challenged by the fact that the evidence supporting widely adopted recommendations in our previous guidelines—such as indications for intracranial pressure (ICP) monitoring—no longer meets current evidence standards prompting the pragmatic but carefully considered approach of restating select old recommendations. The Brain Trauma Foundation prides itself on producing rigorous and transparent evidence-based guidelines of the highest standard. The authors underwent a period of discussion and introspection in preparation for the fourth edition. As the fourth edition2 will serve as the foundation for the “Living Guidelines,” it was essential that the nature of this foundation be very carefully considered. We recognize that the consensus statements recently produced by the Neurocritical Care Society and by the American College of Surgeons supplement evidence with expert opinion. The Brain Trauma Foundation decided not to take this approach. We are mindful that expert opinion can be wrong: noteworthy examples include prophylactic hyperventilation and administration of corticosteroids, which used to be commonplace in the care of the severely brain injured. Evidence has ultimately shown these practices to be harmful. Moreover, the methodology inherent to building consensus-based recommendations or treatment protocols is distinct from those used in a rigorous evidence-based review. With these issues in mind and in the context of current guidelines standards, we made the difficult and important decision to keep our recommendations focused on a strict interpretation of available evidence. In doing so, we believe we have filled a different niche than that occupied by recently published consensus statements. The Brain Trauma Foundation recognizes the tremendous demand for an updated consensus-based treatment protocol which can serve as a template for local protocols reflecting local preferences and resources. The treatment algorithm that the Brain Trauma Foundation developed and published in conjunction with the first3 and second6 edition of the guidelines were very frequently requested reprints. We have been developing an updated protocol7 that conceptualizes the treatment of elevated ICP or brain hypoxia in 3 tiers based on efficacy and risk. This conceptual approach is the basis for what has been adopted by recent high-profile studies including PRoTECT III and TRACKTBI. We are making plans to further develop this protocol incorporating the recommendations of the fourth edition guidelines. We believe that collaboration with other societies and stakeholders will be important to prevent multiple independent efforts, which would result in a further fragmentation of recommendations and conflicting protocols. Although there is much evidence supporting improved outcomes from ICP-directed therapies, evidence does not currently support selective ICP monitoring in severe TBI patient subgroups. We agree with the Parma group that published consensus statements are helpful. We are mindful, though, of the 1982 paper by Narayan et al.8 Though this paper does not meet current evidence standards, it made the important finding that patients in coma with 2 or more of hypotension, posturing, or age over 40 are at risk for ICP elevation despite a normal head computed tomography. This paper has been influential and led some to mandate the exclusion of ICP elevation prior to making a diagnosis of diffuse axonal injury.We recognize that the question of which patients should undergo ICP monitoring remains an appropriately debated aspect of TBI patient care, and we hope that in the future new high-quality data will inform this issue. The ICP treatment threshold has evolved over time in accordance with the available evidence and evidence standards. The main evidence for the current 22 mm Hg threshold comes from the work of Sorrentino et al.9 Though the optimal ICP threshold is still not known with absolute certainty, it is the view of the fourth edition authors that this paper provides the best estimate to date. It is important, of course, that the threshold be reported with as much precision as possible, even though this reflects a small change from the previous edition. We acknowledge that there is some early evidence that different individuals may have different optimal ICP thresholds9; however, this evidence is insufficient for recommendations as yet. In summary, the fourth edition of the Guidelines for the Management of Severe TBI evaluated and weighed available evidence according to current methodological standards, which are now utilized across medical disciplines. The authors were very

Multiple Surgical Teams in the O. R. at Once—Priority of Effort and Who Takes the Lead?

The management of a trauma patient with multiple injuries requires careful coordination prior to and while in the operating room. In order to consistently assure the best possible outcome for these patients a team-based approach is essential. Defining the relative roles for each team and the priority given to each injury is necessary to ensure a coordinated response and hence the best possible outcome. It is important that airway, breathing, and circulation remain the initial priorities and the correction of hemodynamic instability takes precedence over the workup of intracranial lesions. In turn, the management of intracranial injury takes precedence over the surgical fixation of broken bones. At times it is necessary for the trauma team and neurosurgery teams to work simultaneously in the operating room. An intracranial pressure monitor can be placed during laparotomy or thoracotomy in select cases, particularly when a preoperative CT scan cannot be obtained due to the urgent need for operative surgical resuscitation. Fortunately with the widespread and easy availability of around-the-clock CT scanning at most U.S. trauma centers, this is an uncommon scenario. High intracranial pressure can be treated medically until active systemic bleeding is controlled and the blood pressure is stabilized. A craniotomy for intracranial hematoma evacuation should be performed promptly after the hypotension has been corrected. Clear communication and coordination between the anesthesiologist, the trauma surgeon, the neurosurgeon, and other appropriate specialists are vital in order to obtain the best possible outcomes.

Decompressive Craniotomy and Craniectomy for Brain Trauma

Purpose of ReviewThere is still substantial controversy surrounding the utility of decompressive craniectomy (DC) in patients with traumatic brain injury (TBI). Some surgeons readily perform these operations, while others are more hesitant due to concerns about patient outcomes in severe TBI.Recent FindingsIn this paper, the authors outline recent literature regarding the use of DC in TBI patients, starting with a brief background on surgical methods then examining the results of recent retrospective studies, case series, and randomized trials.SummaryDespite the controversy, and while a new randomized control trial is pending publication, DC remains an important tool in managing patients with TBI.