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Aditya Vedantam, Claudia S. Robertson, and Shankar P. Gopinath

D ecompressive craniectomy has been shown to reduce intracranial pressure (ICP) in patients with traumatic brain injury (TBI), although this does not consistently result in favorable clinical outcomes. 2 Unfavorable clinical outcomes after decompressive craniectomy for TBI have been thought to be due to cerebral edema, altered cerebral blood flow (CBF), and metabolic dysfunction. 4 At this time, more data are needed on changes in cerebral hemodynamics after decompressive craniectomy to better assist in prognostication. There are limited data on changes in

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Aditya Vedantam, Claudia S. Robertson, and Shankar P. Gopinath

H ypernatremia has been shown to increase mortality in critically ill patients, independent of comorbidities. 5 , 13 , 14 , 17 Although the negative impact of hypernatremia is well described for patients treated in medical or surgical ICUs, 5 , 14 , 17 there is increased interest in the effects of hypernatremia in patients treated in neurocritical care units. 2 , 18 In particular, few studies have evaluated the independent effect of hypernatremia on mortality after severe traumatic brain injury (TBI). 6 , 15 The relationship between hypernatremia and TBI is

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Aditya Vedantam, Jose-Miguel Yamal, Hyunsoo Hwang, Claudia S. Robertson, and Shankar P. Gopinath

P osttraumatic hydrocephalus (PTH) affects 11.9%–36% of patients undergoing decompressive craniectomy (DC) after traumatic brain injury (TBI). 2 , 4 , 7 , 14 Hydrocephalus often develops more than a month after a patient undergoes DC 21 and can be associated with poorer outcomes. 17 Early diagnosis and treatment of PTH can prevent further neurological compromise in patients who are recovering from TBI. The diagnosis of hydrocephalus in patients with large craniectomy defects remains a challenge. Ventriculomegaly after DC is not always indicative of

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Aditya Vedantam, Jose-Miguel Yamal, Maria Laura Rubin, Claudia S. Robertson, and Shankar P. Gopinath

P rogression of intracranial injury on CT is reported in 8%–67% of patients with blunt traumatic brain injury (TBI). 22 Studies focusing on parenchymal contusions show that progressive hemorrhagic injury occurs in more than 50% of the patients on repeat CT scans. 9 , 14 For the majority of patients with TBI, progression of injury is observed in the first 24–48 hours, 1 , 14 although a few patients can show progression as long as 72 hours after injury. 6 These events are associated with increased morbidity and mortality as well as poorer neurological

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Roukoz Chamoun, Dima Suki, Shankar P. Gopinath, J. Clay Goodman, and Claudia Robertson

, 1994 6 Faden AI , Demediuk P , Panter SS , Vink R : The role of excitatory amino acids and NMDA receptors in traumatic brain injury . Science 244 : 798 – 800 , 1989 7 Gentile NT , McIntosh TK : Antagonists of excitatory amino acids and endogenous opioid peptides in the treatment of experimental central nervous system injury . Ann Emerg Med 22 : 1028 – 1034 , 1993 8 Greenwood SM , Connolly CN : Dendritic and mitochondrial changes during glutamate excitotoxicity . Neuropharmacology 53 : 891 – 898 , 2007 9 Hickenbottom SL

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Aditya Vedantam, Claudia S. Robertson, and Shankar P. Gopinath

O utcomes after severe traumatic brain injury (TBI) are variable, and several studies have focused on predicting clinical outcomes after the injury. 3 , 5 , 7 , 12 , 15 Many studies have described factors associated with mortality and morbidity after severe TBI. 8 , 12 , 14 , 15 However, there are few descriptions of the clinical characteristics of patients with favorable outcomes after severe TBI. 2 , 4 The temporal profile of early recovery after severe TBI has not been examined in detail. It is often difficult to predict when a patient will show clinical

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Roman Hlatky, Alex B. Valadka, Shankar P. Gopinath, and Claudia S. Robertson

Award for Resident Research on Brain and Craniofacial Injury: normoxic ventilatory resuscitation after controlled cortical impact reduces peroxynitrite-mediated protein nitration in the hippocampus . Clin Neurosurg 52 : 348 – 356 , 2005 2 Bardt TF , Unterberg AW , Härtl R , Kiening KL , Schneider GH , Lanksch WR : Monitoring of brain tissue PO2 in traumatic brain injury: effect of cerebral hypoxia on outcome . Acta Neurochir Suppl 71 : 153 – 156 , 1998 3 Dings J , Jager A , Meixensberger J , Roosen K : Brain tissue pO2 and

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Roukoz B. Chamoun, Claudia S. Robertson, and Shankar P. Gopinath

survival using simple clinical variables: a case study in traumatic brain injury . J Neurol Neurosurg Psychiatry 66 : 20 – 25 , 1999 13 Tien HC , Cunha JR , Wu SN , Chughtai T , Tremblay LN , Brenneman FD , : Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? . J Trauma 60 : 274 – 278 , 2006 14 Valadka AB , Injury to the Cranium . Mattox KL , Feliciano DV , Moore EE : Trauma ed 4 New York , McGraw-Hill , 2000 . 377 – 399 15 Waxman K , Sundine

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Charles F. Contant, Alex B. Valadka, Shankar P. Gopinath, H. Julia Hannay, and Claudia S. Robertson

pulmonary capillary permeability. 8, 14 Therefore, the patients with severe traumatic brain injury who are at greatest risk of developing ARDS include those with a history of drug abuse and those with midline shift on their admission CT scan. Nevertheless, because the incidence of these findings was not significantly different between the two treatment groups, these risk factors probably do not explain the increased risk of ARDS in the CBF-targeted group. 2) The treatment-related variables that were associated with an increased risk of ARDS reflected the goals of the

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Sunil Munakomi

TO THE EDITOR: I read with interest a recent article by Vedantam et al. 4 ( Vedantam A, Yamal JM, Hwang H, et al: Factors associated with shunt-dependent hydrocephalus after decompressive craniectomy for traumatic brain injury. J Neurosurg 128:1547–1552, May 2018 ), who concluded that the presence of interhemispheric hygroma and young age are high risk factors for need for CSF shunting for the treatment of hydrocephalus following decompressive hemicraniectomy in patients with traumatic brain injury (TBI). There are few pivotal factors that are cornerstones in