Medical Management of Neurosurgical Patients

Medical Management of Neurosurgical Patients

by Rene Daniel and Catriona M Harrop

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Emerging as a new sub-specialization within the hospitalist community, the neurosurgery hospitalist provides preoperative risk stratification, advises on managing pre- and postoperative complications, and helps doctors make decisions about when to involve specialists other than neurosurgeons. This collaborative approach to the neurosurgery patient has been shown to offer effective care since hospitalists can be better attuned than specialists to multiple medical problems that most patients have.

Medical Management of Neurosurgical Patients is a first of its kind textbook providing a standardized source of information for neurosurgery hospitalists in order to establish a common ground and improve their knowledge and training. The work will focus on the management of CNS infections, management of bleeding in the context of CNS surgery (a potentially catastrophic complication), management of sodium and blood glucose levels including steroid-induced hyperglycemia, perioperative pain control, and management of pressure injuries and rehabilitation in the context of CNS injury.

Posttraumatic seizures management

Posttraumatic seizures management

Patient selection for seizure prophylaxis after traumatic brain injury (TBI) and duration of antiepileptic drug treatment for patients with early posttraumatic seizures (PTS) remain plagued with uncertainty. In early 2017, a collaborative group of neurosurgeons, neurologists, neurointensive care and rehabilitation medicine physicians was formed in the UK with the aim of assessing variability in current practice and gauging the degree of uncertainty to inform the design of future studies. The survey results demonstrated the variation in practice and uncertainty in both described aspects of management of patients who have suffered a TBI. The majority of respondents would want to participate in future research to help try and address this critical issue, and this shows the importance and relevance of these two clinical questions 1)

Recommendations

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

Level I

• There was insufficient evidence to support a Level I recommendation for this topic.

Level II A

• Prophylactic use of phenytoin or valproate is not recommended for preventing late PTS.

• Phenytoin is recommended to decrease the incidence of early PTS (within 7 days of injury), when the overall benefit is felt to outweigh the complications associated with such treatment. However, early PTS have not been associated with worse outcomes. At the present time there is insufficient evidence to recommend levetiracetam over phenytoin regarding efficacy in preventing early post-traumatic seizures and toxicity.

Changes from Prior Edition

The recommendations have not changed for this update from the 3rd Edition. Two new Class 2 studies and four new Class 3 studies were added as evidence, but these and the Class 3 studies included from the 3rd Edition did not provide sufficient evidence to inform new recommendations.

Prevention

Treatment

Meta-analysis

Wilson et al. assessed and compared the effectiveness of drugs on early and late PTS prevention.

A literature search revealed 120 articles. Data were included if the same factors were compared across studies with identical treatment arms. Random effects models were used for meta-analysis to combine data into an overriding odds ratio (OR) comparing PTS incidence. For early PTSs, PHT was compared with placebo and LEV with PHT. For late PTSs, each drug was compared with a placebo.

Sixteen studies were included. PHT was associated with decreased odds of early seizures relative to placebo (OR = 0.34, 95% confidence interval [CI] 0.19-0.62). There was no difference in early seizure incidence between LEV and PHT (OR = 0.83, 95% CI 0.33-2.1). Neither LEV (OR = 0.69, 95% CI 0.24-1.96) nor PHT (OR = 0.4, 95% CI 0.1-1.6) was associated with fewer late PTSs than placebo.

New literature is consistent with current guidelines supporting antiepileptic drug administration for prevention of early, but not late, PTSs. With regard to early PTS prevention, LEV and PHT are similarly efficacious, which is consistent with current guidelines. Side-effect profiles favor LEV administration over PHT 2).

References

1)

Mee H, Kolias AG, Chari A, Ercole A, Lecky F, Turner C, Tudur-Smith C, Coles J, Anwar F, Belli A, Manford M, Ham T, McMahon C, Bulters D, Uff C, Duncan JS, Wilson MH, Marson AG, Hutchinson PJ. Pharmacological management of post-traumatic seizures in adults: current practice patterns in the UK and the Republic of Ireland. Acta Neurochir (Wien). 2019 Mar;161(3):457-464. doi: 10.1007/s00701-018-3683-9. Epub 2018 Oct 1. PubMed PMID: 30276544; PubMed Central PMCID: PMC6407744.
2)

Wilson CD, Burks JD, Rodgers RB, Evans RM, Bakare AA, Safavi-Abbasi S. Early and Late Posttraumatic Epilepsy in the Setting of Traumatic Brain Injury: A Meta-analysis and Review of Antiepileptic Management. World Neurosurg. 2018 Feb;110:e901-e906. doi: 10.1016/j.wneu.2017.11.116. Epub 2017 Dec 2. Review. PubMed PMID: 29196247.

Traumatic Brain Injury: Assessment and Management

Traumatic Brain Injury: Assessment and Management

$127.24

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Traumatic brain injury (TBI), also referred to as intracranial injury, occurs due to trauma to the brain. It can cause a range of physical, cognitive, behavioral, social and emotional symptoms. Its outcome can vary from complete recovery to permanent disability or death. TBI can occur due to an accident, physical violence or a fall. Its diagnosis involves the use of techniques like magnetic resonance imaging (MRI) and computed tomography. Depending on the extent of the injury, confirmed through a diagnosis, treatment can be minimal or extensive involving medications, surgery and rehabilitation therapies. This book discusses the fundamental as well as modern approaches in the assessment and management of traumatic brain injury. The topics included in this book are of utmost significance and bound to provide incredible insights to readers. It will prove to be immensely beneficial to students and researchers in this domain.

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