̽��ֱ�� of Cambridge - Angelos Kolias

International study recommends replacing skull section after treatment for a brain bleed

cjb250 — Sun, 23 Apr 2023 19:30:09 +0000

̽��ֱ��RESCUE-ASDH trial, funded by the UK’s National Institute for Health and Care Research (NIHR), involved 40 centres in 11 countries and involved 450 patients. ̽��ֱ��results of the trial are published today in the New England Journal of Medicine and are announced at the annual meeting of the American Association of Neurological Surgeons.

One of the potentially life-threatening results of head injury is a so-called acute subdural haematoma – a bleed that occurs between the brain and skull and can lead to the build-up of pressure. Such haemorrhages require surgery to stem the bleeding, remove the blood clot and relieve the pressure.

At present, there are two approaches to such surgery. One approach is a decompressive craniectomy, which involves leaving a section of the skull out – which can be as large as 13cm in length – in order to protect the patient from brain swelling, often seen with this type of haemorrhage. ̽��ֱ��missing skull typically will need to be reconstructed and in some treatment centres, the patient’s own bone will be replaced several months after surgery, while at other centres a manufactured plate is used.

̽��ֱ��second approach is a craniotomy, in which the skull section is replaced after the haemorrhage has been stemmed and the blood clot removed. This approach will obviate the need for a skull reconstruction further down the line.

To date there has been little conclusive evidence and hence no uniformly accepted criteria for which approach to use. To solve this question, an international team led by researchers at the ̽��ֱ�� of Cambridge and Cambridge ̽��ֱ�� Hospitals NHS Foundation Trust carried out a randomised trial – RESCUE-ASDH – in which patients undergoing surgery for traumatic acute subdural haematoma were randomly assigned to undergo decompressive craniectomy or craniotomy.

A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. ̽��ֱ��researchers assessed the outcomes for these patients and their quality of life up to a year after surgery, as measured on clinical evaluation scales.

Patients in both groups had similar disability-related and quality-of-life outcomes at 12 months post-surgery, with a trend – which was not statistically significant – towards better outcomes with craniotomy.

Around one in four patients (25.6%) in the craniotomy group and one in five (19.9%) in the decompressive craniectomy group had a good recovery as measured on the scales.

Around one in three patients in both groups (30.2% of patients in the craniotomy group and 32.2% of those in the decompressive craniectomy group) died within the first 12 months following surgery.

14.6% of the craniotomy group and 6.9% of the decompressive craniectomy group required additional cranial surgery within two weeks after randomisation. However, this was balanced against the fact that fewer people in the craniotomy group experienced wound complications (3.9% against 12.2% of the decompressive craniectomy group).

Professor Peter Hutchinson, Professor of Neurosurgery at Cambridge and the trial's Chief Investigator, said: " ̽��ֱ��international randomised trial RESCUE-ASDH is the first multicentre study to address a very common clinical question: which technique is optimal for removing an acute subdural haematoma – a craniotomy (putting the bone back) or a decompressive craniectomy (leaving the bone out)?

“This was a large trial and the results convincingly show that there is no statistical difference in the 12 month disability-related and quality of life outcomes between the two techniques.”

Professor Angelos Kolias, Consultant Neurosurgeon at Cambridge and the trial's Co-chief Investigator, said: "Based on the trial findings, we recommend that after removing the blood clot, if the bone flap can be replaced without compression of the brain, surgeons should do so, rather than performing a pre-emptive decompressive craniectomy.

“This approach will save patients from having to undergo a skull reconstruction, which carries the risk of complications and additional healthcare costs, further down the line.”

̽��ֱ��researchers point out, however, that the findings may not be relevant for resource-limited or military settings, where pre-emptive decompressive craniectomy is often used owing to the absence of advanced intensive care facilities for post-operative care.

Professor Andrew Farmer, Director of NIHR’s Health Technology Assessment (HTA) Programme, said: “ ̽��ֱ��findings of this world-leading trial provide important evidence which will improve the way patients with head injuries are treated. High quality, independently funded research like this is vital in providing evidence to improve health and social care practice and treatments. Research is crucial in informing those who plan and provide care.”

̽��ֱ��RESCUE-ASDH trial was supported by the NIHR Global Health Research Group on Acquired Brain and Spine Injury, the CENTER-TBI project of the European Brain Injury Consortium, and the Royal College of Surgeons of England Clinical Research Initiative.

Reference
Hutchinson, PJ et al. Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma. NEJM; 23 Apr 2023; DOI: 10.1056/NEJMoa2214172

A major international trial has concluded that, where possible, surgeons should replace the removed section of the skull following surgery to treat a form of brain haemorrhage. This approach will save patients from having to undergo skull reconstruction further down the line.

This approach will save patients from having to undergo a skull reconstruction, which carries the risk of complications and additional healthcare costs, further down the line

Angelos Kolias

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Largest ever study on traumatic brain injury highlights global inequality in causes and treatment

cjb250 — Wed, 16 Mar 2022 23:30:44 +0000

̽��ֱ��Global Neurotrauma Outcomes Study, funded by the NIHR, is published in ̽��ֱ��Lancet Neurology and provides data to assist in decision making and improving outcome for patients with traumatic brain injury globally.

̽��ֱ��paper focuses on types of cases, the way they are managed, and death rates, and was compiled using data submitted by 159 hospitals in 57 countries to a central database, which the researchers then analysed. ̽��ֱ��researchers stratified countries into four tiers (very high, high, medium, low) according to their Human Development Index (HDI), which takes account of factors like life expectancy, education, and income.

̽��ֱ��prospective study determined that patients in the low HDI tier were often young and tended to suffer skull fractures due to assault but were classified as ‘mild’ traumatic brain injury (TBI).

In the medium and high HDI tiers, patients were also young, but most had moderate to severe TBI caused by a road traffic collision and extradural haematoma – a bleed on the outside of the dura mater, the membrane covering of the brain.

In the very high tier, patients tended to be older and presented with a moderate or severe TBI associated with a fall and acute subdural haematoma - a bleed on the inner surface of the dura mater.

Image: Map showing most common causes of traumatic brain injury: fall, road traffic collision (RTC), and assault.

Quality of care was generally less favourable in lower HDI settings, including delays to surgery and a lack of postoperative monitoring equipment and intensive care. ̽��ֱ��very high HDI tier had the highest proportion of operations in which the most senior surgeon present in the operating theatre was a fully qualified neurosurgeon, while the medium HDI tier had the lowest proportion. ̽��ֱ��study also found significant variations between hospitals in the outcome of patients.

Angelos Kolias, Consultant Neurosurgeon at Cambridge ̽��ֱ�� Hospitals NHS Foundation Trust (CUH) and NIHR Global Neurotrauma Research Group associate director, said: “ ̽��ֱ��results show that overall mortality is low, reflecting the life-saving nature of surgery for traumatic brain injuries. Many of these patients would have died without an operation. However, we also need to address deficits in pre-hospital management and long-term rehabilitation.”

David Clark, a trainee neurosurgeon and ̽��ֱ�� of Cambridge research fellow, said: “A particularly important finding is that outcome is influenced more by hospital characteristics than country of origin, which raises the possibility that changing the systems and processes of care in individual hospitals might be able to improve mortality. ̽��ֱ��paper sows the seeds for discussion and change.”

̽��ֱ��research was funded by the NIHR using UK government aid to support global health research.

Alexis Joannides, Consultant Neurosurgeon at CUH and NIHR Global Neurotrauma Research Group informatics lead, added: “ ̽��ֱ��contribution of several clinicians and researchers from several hospitals across the world has been possible due to the infrastructure and collaborations supported by the NIHR.

“ ̽��ֱ��database and data management process used in the study have now laid the foundation for a global registry of traumatic brain injuries that we have established to support ongoing quality improvement and research in the field of traumatic brain injury.”

Peter Hutchinson, Professor of Neurosurgery at the ̽��ֱ�� of Cambridge and Director of the NIHR Global Neurotrauma Research Group, said: “This is the largest study in the world looking at the surgical management of head injuries and will be of practical value to clinicians and others planning strategies for the future.

“ ̽��ֱ��collaboration across such a vast number of hospitals and countries, together with the support of the World Federation of Neurosurgical Societies and continental neurosurgical societies, has been phenomenal.”

Reference
Clark, D et al. Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study. ̽��ֱ��Lancet Neurology; 17 March 2022; DOI: 10.1016/S1474-4422(22)00037-0

Adapted from a press release from Cambridge ̽��ֱ�� Hospitals NHS Foundation Trust

Neurosurgery experts from Cambridge have led the largest ever study examining the surgical management of traumatic brain injuries, highlighting regional inequalities in both major causes and treatment of such injuries.

This is the largest study in the world looking at the surgical management of head injuries and will be of practical value to clinicians and others planning strategies for the future

Peter Hutchinson

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Common drug for build-up of blood following head injury worse than placebo, study finds

cjb250 — Wed, 16 Dec 2020 22:00:11 +0000

Chronic subdural haematoma is one of the most common neurological disorders and mainly affects older people. People affected often have headaches, deteriorating memory, confusion, balance problems or limb weakness. Surgery to drain the liquid collection is effective with the majority of patients improving.

A commonly used steroid, dexamethasone, has been used alongside surgery or instead of it since the 1970s. However, consensus has been lacking regarding the use of dexamethasone, especially since no high-quality studies confirming its effectiveness had been conducted until now.

With funding from the UK National Institute Health Research, a group of doctors and researchers from 23 neurosurgical units in the United Kingdom enrolled 748 patients with chronic subdural haematoma in the “Dexamethasone in Chronic Subdural Haematoma (Dex-CSDH)” randomised trial. A total of 375 patients were randomised to receive a two-week tapering course of dexamethasone and were compared with 373 patients randomised to an identical matching placebo.

̽��ֱ��results of the study, published today in the New England Journal of Medicine, show that patients who received dexamethasone had a lower chance of favourable recovery at six months compared to patients who received placebo. More specifically, the vast majority of patients in both groups had an operation to drain the haematoma and had experienced significant functional improvement at six months compared to their initial admission to hospital.

Fewer patients in the dexamethasone group required repeat surgery for a recurrent haematoma compared to patients in the placebo group. However, 84% of patients who received dexamethasone had recovered well at 6 months compared to 90% of patients who received placebo.

Peter Hutchinson, Professor of Neurosurgery at the ̽��ֱ�� of Cambridge and the trial’s Chief Investigator, said: “Chronic subdural haematoma has been steadily increasing in frequency over the past decades. Patients affected are often frail and have other co-existing medical conditions. Since the 1970s, dexamethasone has been used as a drug alongside or instead of surgery with a few studies reporting good results.

“Our trial sought to determine if dexamethasone should be offered routinely to all patients with chronic subdural haematoma or if its use should be abandoned. Based on our findings, we believe that dexamethasone should not be used in patients with chronic subdural haematoma anymore.”

Angelos Kolias, Lecturer of Neurosurgery at the ̽��ֱ�� of Cambridge and the trial’s Co-chief Investigator, added: “ ̽��ֱ��results of the study were surprising given that dexamethasone seemed to help reduce the number of repeat surgeries. However, this simply reinforces the importance of conducting high-quality trials with patient-reported outcomes as the main outcomes of interest”.

Ellie Edlmann, the trial’s research fellow, currently a Clinical Lecturer at the ̽��ֱ�� of Plymouth, concluded: “Credit is due to all doctors and researchers from across the NHS who worked tirelessly in order to enrol all eligible patients in the trial; in particular, the role of trainee neurosurgeons, members of the British Neurosurgical Trainee Research Collaborative, needs to be highlighted. We sincerely thank all patients and their carers, as without their altruistic participation, this trial would not have been possible.”

̽��ֱ��trial was funded by the National Institute for Health Research (NIHR), with further support from the NIHR Cambridge Biomedical Research Centre, the NIHR Brain Injury MedTech Co-operative, the Royal College of Surgeons of England, and the Rosetrees Trust.

Reference
Hutchinson, PJ et al. Trial of Dexamethasone for Chronic Subdural Hematoma. NEJM; 16 Dec 2020; DOI: 10.1056/NEJMoa2020473

A commonly-used treatment for chronic subdural haematoma – the build-up of ‘old’ blood in the space between the brain and the skull, usually as a result of minor head injury – could lead to a worse outcome than receiving no medication, suggests new research from the ̽��ֱ�� of Cambridge.

Our trial sought to determine if dexamethasone should be offered routinely to all patients with chronic subdural haematoma or if its use should be abandoned. Based on our findings, we believe that dexamethasone should not be used in patients with chronic subdural haematoma anymore

Peter Hutchinson

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Opening the skull of patients after head injury reduces risk of death from brain swelling

sjr81 — Thu, 08 Sep 2016 07:44:32 +0000

Traumatic brain injury is a serious injury to the brain, often caused by road traffic accidents, assaults or falls. It can lead to dangerous swelling in the brain which, in turn, can lead to brain damage or even death.

A team led by researchers at the Department of Clinical Neurosciences, ̽��ֱ�� of Cambridge, and based at Addenbrooke's Hospital, recruited over 400 traumatic brain injury patients over a ten-year period from the UK and another 19 countries worldwide. They then randomly assigned the patients to one of two groups for treatment – craniectomy or medical management.

In research published this week in the New England Journal of Medicine, the researchers report that six months after the head injury, just over one in four patients (27%) who received a craniectomy had died compared to just under a half (49%) of patients who received medical management. However, the picture was complicated as patients who survived after a craniectomy were more likely to be dependent on others for care (30.4% compared to 16.5%).

Further follow-up showed that patients who survived following a craniectomy continued improving from six to 12 months after injury. As a result, at 12 months, nearly half of craniectomy patients were at least independent at home (45.4%), as compared with one-third of patients in the medical group (32.4%).

Peter Hutchinson, Professor of Neurosurgery at the Department of Clinical Neurosciences at Cambridge, says: “Traumatic brain injury is an incredibly serious and life-threatening condition. From our study, we estimate that craniectomies can almost halve the risk of death for patients with a severe traumatic brain injury and significant swelling. Importantly, this is the first high-quality clinical trial in severe head injury to show a major difference in outcome. However, we need to be really conscious of the quality of life of patients following this operation which ranged from vegetative state through varying states of disability to good recovery.”

Angelos Kolias, Clinical Lecturer at the Department, adds: “Doctors and families will need to be aware of the wide range of possible long-term outcomes when faced with the difficult decision as to whether to subject someone to what is a major operation. Our next step is to look in more detail at factors that predict outcome and at ways to reduce any potential adverse effects following surgery. We are planning to hold a consensus meeting in Cambridge next year to discuss these issues.”

̽��ֱ��research was funded by the Medical Research Council (MRC) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC–NIHR partnership, with further support from the NIHR Cambridge Biomedical Research Centre, the Academy of Medical Sciences, the Health Foundation, the Royal College of Surgeons of England and the Evelyn Trust.

Reference

Hutchinson, PJ et al. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension, NEJM; 2 Sept 2016

Craniectomy – a surgical procedure in which part of the skull is removed to relieve brain swelling – significantly reduces the risk of death following traumatic brain injury, an international study led by the ̽��ֱ�� of Cambridge has found.

Traumatic brain injury is an incredibly serious and life-threatening condition. From our study, we estimate that craniectomies can almost halve the risk of death for patients with a severe traumatic brain injury and significant swelling.

Peter Hutchinson

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