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Robert G. Whitmore, Jayesh P. Thawani, M. Sean Grady, Joshua M. Levine, Matthew R. Sanborn, and Sherman C. Stein

. 6 However, we have corrected the estimates of Faul et al., 6 which were based on average costs for all hospitalized traumatic brain injury (TBI) patients, not just for those with severe TBI. We used a formula that relied on the relative cost of a day in the ICU being approximately 3 times as much as care on a medical-surgical floor. 9 Hence, in contrast to the calculations of Faul et al., in our calculations, hospitalization for the aggressive-treatment group costs considerably more than that for the routine-care group. Average ICU and hospital stays for the

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Michael F. Stiefel, Alejandro Spiotta, Vincent H. Gracias, Alicia M. Garuffe, Oscar Guillamondegui, Eileen Maloney-Wilensky, Stephanie Bloom, M. Sean Grady, and Peter D. LeRoux

well as therapy directed at brain O 2 can be associated with a reduced patient mortality rate after severe TBI. Acknowledgments We acknowledge the hard work performed by the nurses in the HUP neurosurgical ICU in caring for these patients as well as their help in data acquisition. References 1. Bardt TF , Unterberg AW , Hartl 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 (Wien) 71

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Matthew F. Philips, Gustav Mattiasson, Tadeusz Wieloch, Anders Björklund, Barbro B. Johansson, Gregor Tomasevic, Alberto Martínez-Serrano, Philipp M. Lenzlinger, Grant Sinson, M. Sean Grady, and Tracy K. McIntosh

injury: a light and electron microscopic study in rats. J Neurotrauma 11 : 289 – 301 , 1994 Dietrich WD, Alonso O, Halley M: Early microvascular and neuronal consequences of traumatic brain injury: a light and electron microscopic study in rats. J Neurotrauma 11: 289–301, 1994 10. Dixon CE , Flinn P , Bao J , et al : Nerve growth factor attenuates cholinergic deficits following traumatic brain injury in rats. Exp Neurol 146 : 479 – 490 , 1997 Dixon CE, Flinn P, Bao J, et al: Nerve growth factor

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Michael D. Cusimano, Katrina Zanetti, and Conor Sheridan

T o T he E ditor : We read with interest the article by Whitmore et al. 4 (Whitmore RG, Thawani JP, Grady MS, et al: Is aggressive treatment of traumatic brain injury cost-effective? Clinical article. J Neurosurg 116: 1106–1113, May 2012). This unique and nicely crafted research insightfully addressed the cost of more and less aggressive treatment approaches for traumatic brain injury (TBI) from the perspective of the patient and the health care system. The authors defined aggressive treatment as adhering to the Brain Trauma Foundation (BTF) guidelines

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M. Sean Grady

of Neurosurgery at the University of Pennsylvania. During that interval, he initiated the work in traumatic brain injury for which he would become famous worldwide. I also understand from talking with some of his compatriots in that work that there were some disconcerting times when some of the animals escaped from their cages and went prowling around the hospital until their recapture. F ig. 1. Photograph of Thomas Langfitt. Dr. Langfitt attracted some of the best and brightest people to help him pursue his work. These individuals—who have gone on to

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Richard H. Schmidt and M. Sean Grady

O ver 500,000 people in the United States sustain traumatic brain injuries each year; the vast majority are between the ages of 11 and 40 years. 25 Although 360,000 of these injuries are mild (Glasgow Coma Scale (GCS) 19 13–15), over 70,000 persons die from head injury annually, and another 70,000 individuals survive after suffering moderate (GCS 9–12) or severe (GCS 3–8) brain injury. Apart from focal deficits attributable to injury of specific sensory and motor pathways, head injury is associated with pervasive disturbances in consciousness and cognitive

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Peter D. Le Roux, David W. Newell, Arthur M. Lam, M. Sean Grady, and H. Richard Winn

poor relationship between CPP and AVDO 2 . However, limited improvement in an elevated AVDO 2 following craniotomy for traumatic mass lesions or mannitol administration for intracranial hypertension was significantly associated with delayed cerebral infarction and poor outcome. By contrast, a large improvement in AVDO 2 was associated with favorable outcome and no evidence of delayed cerebral infarction. Clinical Material and Methods Patient Population During a 12-month period, 32 patients with severe traumatic brain injury (postresuscitation Glasgow Coma

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Peter D. Le Roux, David W. Newell, Arthur M. Lam, M. Sean Grady, and H. Richard Winn

Jugular bulb oxygen monitoring can be used to estimate the adequacy of cerebral blood flow to support cerebral metabolism after severe head injury. In the present study, the authors studied the cerebral arteriovenous oxygen difference (AVDO2) before and after treatment in 32 head-injured patients (Glasgow Coma Scale scores ¾ 8) to examine the relationships among AVDO2 and cerebral perfusion pressure (CPP), delayed cerebral infarction, and outcome. Fifteen patients (Group A) underwent craniotomy for hematoma evacuation and 17 (Group B) received mannitol for sustained intracranial hypertension (intracranial pressure > 20 mm Hg, > 10 minutes). Radiographic evidence of delayed cerebral infarction was observed in 14 patients. Overall, 17 patients died or were severely disabled. Cerebral AVDO2 was elevated before craniotomy or mannitol administration; the mean AVDO2 for all patients before treatment was 8.6 ± 1.8 vol%. Following craniotomy or mannitol administration, the AVDO2 decreased in 27 patients and increased in five patients (mean AVDO2 6.2 ± 2.1 vol% in all patients; 6 ± 1.9 vol% in Group A; and 6.4 ± 2.4 vol% in Group B). The mean CPP was 75 ± 9.8 mm Hg and no relationship with AVDO2 was demonstrated. Before treatment, the AVDO2 was not associated with delayed cerebral infarction or outcome. By contrast, a limited improvement in elevated AVDO2 after craniotomy or mannitol administration was significantly associated with delayed cerebral infarction (Group A: p < 0.001; Group B: p < 0.01). Similarly, a limited improvement in elevated AVDO2 after treatment was significantly associated with an unfavorable outcome (Group A: p < 0.01; Group B: p < 0.001). In conclusion, these findings strongly indicate that, despite adequate cerebral perfusion, limited improvement in elevated cerebral AVDO2 after treatment consisting of either craniotomy or mannitol administration may be used to help predict delayed cerebral infarction and poor outcome after traumatic brain injury.

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Niklas Marklund, Florence M. Bareyre, Nicolas C. Royo, Hilaire J. Thompson, Anis K. Mir, M. Sean Grady, Martin E. Schwab, and Tracy K. McIntosh

increase regeneration, plasticity and functional recovery of the lesioned central nervous system . Ann Med 37 : 556 – 567 , 2005 9 Cadelli D , Schwab ME : Regeneration of lesioned septohippocampal acetylcholinesterase-positive axons is improved by antibodies against the myelin-associated neurite growth inhibitors NI-35/250 . Eur J Neurosci 3 : 825 – 832 , 1991 10 Christman CW , Salvant JB , Walker SA , Povlishock JT : Characterization of a prolonged regenerative attempt by diffusely injured axons following traumatic brain injury in the adult

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Editorial

Brain tissue oxygen monitoring

M. Sean Grady

Martini and colleagues 1 are to be congratulated on a well-performed study that examines whether brain tissue oxygen (PbO 2 ) monitoring affects treatment and outcome in patients with severe traumatic brain injury. Using a significantly large population of patients admitted to a single center, the authors compared neurological outcome in 122 patients who underwent combined PbO 2 and ICP monitoring with 506 patients in whom ICP monitoring alone was used. There were several fundamental differences between the patients in each group. Those patients who