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Oren Sagher

Much has been made in recent years of a volume effect in most aspects of medical care. Evidence for a volume effect has been noted in a variety of surgical procedures and medical treatments. This robust effect has been used both by specialty boards for certification and by third-party payers for reimbursement. It comes as no surprise, therefore, that a volume effect would be seen in the treatment of traumatic brain injuries (TBIs). In the accompanying study by Shi et al., 1 an analysis of all TBIs in Taiwan over a decade-long period yields very similar

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Oren Sagher and Hemant A. Parmar

Shin et al. 2 describe their findings in a patient with traumatic brain injury (TBI) using high-definition fiber tracking (HDFT), attempting to show the capabilities of this new technique in assessing white matter injuries that are not apparent in standard anatomical imaging. Standard diffusion tensor imaging (DTI) has long held this promise, but the results have been somewhat disappointing and inconsistent due to the lack of good resolution at the voxel level and due to the presence of crossing fibers within the given voxel. The presence of different

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Oren Sagher

. Reference 1 Bailes JE , Petraglia AL , Omalu BI , Nauman E , Talavage T : Role of subconcussion in repetitive mild traumatic brain injury. A review . J Neurosurg [epub ahead of print August 23, 2013. DOI: 10.3171/2013.7.JNS121822]

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Oren Sagher

Conventional wisdom holds that visible injury to the brainstem in the setting of traumatic brain injury (TBI) is an ominous sign that, more often than not, leads to a poor neurological outcome. This assumption is based on older studies that used either CT scans or early MRI techniques, which begs the question of whether it holds true with the increasingly sensitive sequences used in modern MRI scans. Chew et al. 1 examined this question in a large cohort of patients with TBI at a single large Level 1 trauma center. Among nearly 9000 patients seen over a 6

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Oren Sagher

The resuscitation of patients with ischemic neurological injuries has changed dramatically over the last decade, with the advent of increasingly sophisticated ways available to establish and maintain controlled hypothermia. It is now standard practice to treat patients with global ischemic states (for example, cardiac arrest) with aggressive hypothermia to reduce neurological sequelae. 1 , 2 It was therefore only logical to extend the indications to traumatic brain injury (TBI). Two multicenter, randomized trials of controlled hypothermia (National Acute

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Oren Sagher

The accompanying article by Lazaridis et al. describes in detail a study challenging the conventional wisdom of traditional intracranial pressure (ICP) monitoring in the setting of traumatic brain injury (TBI). 3 A number of recent studies have failed to show that controlling or reducing ICP below an absolute threshold results in improvement in neurological outcome or mortality rate. Prior reports have challenged the dogma of ICP monitoring as well. 1 , 2 Still, most centers continue to treat posttraumatic brain swelling with control of the absolute ICP

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Oren Sagher

The development of treatment guidelines from the Brain Trauma Foundation (BTF) had, as its goal, the provision of a treatment standard that could be applied broadly to trauma centers, allowing for high-quality care of brain-injured patients regardless of location. One of the recommendations of the BTF was the institution of intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI) (Glasgow Coma Scale [GCS] score ≤ 8 and head Abbreviated Injury Scale [AIS] score ≥ 3). This recommendation has not been universally adopted

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Oren Sagher and John E. McGillicuddy

. Although Schneider and others clearly recognized the importance of reducing direct impact forces and lengthening the period of impact, a clear understanding of traumatic brain injury was in its infancy at the time. Consequently, the testing of protective gear was fairly elementary and did not include the modeling of rotational acceleration forces. Our understanding of sports-related concussion has greatly improved over the subsequent 4 decades, and we are now in the position to examine protective gear with far better models and metrics. FIG. 1. Signal traces of

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Oren Sagher

The accompanying article by Bor-Seng-Shu et al. 1 attempts to address a rather straightforward question: Does decompressive craniectomy reduce intracranial pressure (ICP) and increase cerebral perfusion pressure (CPP) in the setting of traumatic brain injury? While conventional wisdom would hold this as a foregone conclusion, studies that have included this information have not been entirely conclusive. Moreover, most studies on the topic have been rather small and have not had sufficient power to arrive at a conclusion. The authors of this pooled analysis