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Roman Hlatky, Alex B. Valadka, and Claudia S. Robertson

Arterial hypotension and intracranial hypertension are detrimental to the injured brain. Although artificial elevation of cerebral perfusion pressure (CPP) has been advocated as a means to maintain an adequate cerebral blood flow (CBF), the optimal CPP for the treatment of severe traumatic brain injury (TBI) remains unclear. In addition, CBF evolves significantly over time after TBI, and CBF may vary considerably in patient to patient. For these reasons, a more useful approach may be to consider the optimal CPP in an individual patient at any given time, rather than having an arbitrary goal applied uniformly to all patients. Important information for optimizing CBF is provided by monitoring intracranial pressure in combination with assessment of the adequacy of CBF by using global indicators (for example, jugular oximetry), supplemented when appropriate by local data, such as brain tissue oxygen tension.

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Alex B. Valadka, Andrew I. R. Maas, and Franco Servadei

T he Edwin Smith papyrus is the oldest known written guideline for the treatment of trauma. Injuries to the brain feature prominently in that ancient text. More than three and a half millennia later, traumatic brain injury (TBI) continues to fascinate and frustrate clinicians and researchers alike. This issue of Neurosurgical Focus received an overwhelming number of submissions. The variety of ways in which the authors attempted to improve our understanding of TBI was extraordinary: from acute to chronic, mild to severe, adult to pediatric, closed to open

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Alex B. Valadka, Yu Furuya, Roman Hlatky, and Claudia S. Robertson

The disturbance of normal mechanisms of oxygen delivery and metabolism is a hallmark of severe traumatic brain injury (TBI). In the past, investigations into the status of cerebral oxygen metabolism depended on changes in the differences in oxygen content between arterial and jugular venous blood. The development of jugular venous oximetry permitted continuous monitoring of jugular venous oxygen saturation, thereby overcoming earlier limitations caused by intermittent sampling. Neuromonitoring techniques that utilize only jugular vein sampling provide information only about global cerebral metabolism, but direct measurement of brain tissue oxygen tension via intraparenchymal probes makes possible the assessment of regional cerebral oxygen metabolism. Regional and global neuromonitoring techniques are not competitive or mutually exclusive. Rather, they are best regarded as complementary, with each providing valuable information that has a direct bearing on patient outcomes. The authors review the currently available techniques used in the monitoring of cerebral oxidative metabolism in patients who have sustained severe TBI.

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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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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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Manuela Cormio, Alex B. Valadka, and Claudia S. Robertson

adequacy of cerebral oxygen metabolism. It has been shown that cerebral hemodynamic and metabolic variables in traumatic brain injury do not necessarily correlate with CPP. In a porcine model of cryogenic brain injury, Zhuang, et al., 30 found persistent posttraumatic ischemia despite normalization of CPP. They proposed a significant increase in CVR as the cause of the ischemia. A relationship between clinical condition, CMRO 2 , and outcome after traumatic coma has been noted by several authors. 10, 17–19, 26 Shalit, et al., 26 found that CMRO 2 values below 1.4 ml

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Alex B. Valadka, Jaclyn S. Valadka, Patrick R. Valadka, and Patricia C. Valadka

as neurosurgeons when we give a patient a diagnosis of glioblastoma, or tell a family that their loved one has just suffered a devastating stroke or traumatic brain injury, or similar types of encounters. Our patients’ and their family members’ lives are turned upside down by such diagnoses. Our minimum responsibility is to describe for them the diagnosis, prognosis, treatment plan, and what to expect in the coming days and weeks. But at such emotional moments, it would be very charitable to take some extra time with these patients and families and answer questions

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Charles F. Opalak, Rafael A. Vega, Jodi L. Koste, R. Scott Graham, and Alex B. Valadka

The Department of Neurosurgery at the Medical College of Virginia/Virginia Commonwealth University (VCU) celebrates its 100th anniversary in 2019. It was founded by C. C. Coleman, who directed the US Army School of Brain Surgery during World War I and was one of the original members of the Society of Neurological Surgeons. Coleman began a residency program that was among the first four such programs in the United States and that produced such prominent graduates as Frank Mayfield, Gayle Crutchfield, and John Meredith. Neurosurgery at VCU later became a division under the medical school’s surgery department. Division chairs included William Collins and Donald Becker. It was during the Becker years that VCU became a leading National Institutes of Health–funded neurotrauma research center. Harold Young oversaw the transition from division to department and expanded the practice base of the program. In 2015, Alex Valadka assumed leadership and established international collaborations for research and education. In its first 100 years, VCU Neurosurgery has distinguished itself as an innovator in clinical research and an incubator of compassionate and service-oriented physicians.

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Charles F. Opalak, Rafael A. Vega, Jodi L. Koste, R. Scott Graham, and Alex B. Valadka

The Department of Neurosurgery at the Medical College of Virginia/Virginia Commonwealth University (VCU) celebrates its 100th anniversary in 2019. It was founded by C. C. Coleman, who directed the US Army School of Brain Surgery during World War I and was one of the original members of the Society of Neurological Surgeons. Coleman began a residency program that was among the first four such programs in the United States and that produced such prominent graduates as Frank Mayfield, Gayle Crutchfield, and John Meredith. Neurosurgery at VCU later became a division under the medical school’s surgery department. Division chairs included William Collins and Donald Becker. It was during the Becker years that VCU became a leading National Institutes of Health–funded neurotrauma research center. Harold Young oversaw the transition from division to department and expanded the practice base of the program. In 2015, Alex Valadka assumed leadership and established international collaborations for research and education. In its first 100 years, VCU Neurosurgery has distinguished itself as an innovator in clinical research and an incubator of compassionate and service-oriented physicians.

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Loyola V. Gressot, Roukoz B. Chamoun, Akash J. Patel, Alex B. Valadka, Dima Suki, Claudia S. Robertson, and Shankar P. Gopinath

Object

Prediction of outcome from initial presentation after a gunshot wound to the head (GSWH) is essential to further clinical decision making. The authors' goals are to report the survival and functional outcomes of these patients, to identify prognostic factors, and to propose a scoring system that can predict their outcome.

Methods

The records of 199 patients admitted with a GSWH with dural penetration between 1990 and 2008 were retrospectively reviewed. The inclusion criterion was a CT scan available for review. Patients declared brain dead on presentation were excluded, which yielded a series of 119 patients. Statistical analysis was performed using a logistic regression model.

Results

Fifty-eight (49%) of the 119 patients died. Twenty-three patients (19%) had a favorable outcome defined as a 6-month Glasgow Outcome Scale (GOS) score of moderate disability or good recovery, 35 (29%) had a poor outcome (GOS of persistent vegetative state or severe disability), and 3 (3%) were lost to follow-up. Significant prognostic factors for mortality were age older than 35 years, nonreactive pupils, bullet trajectory of bihemispheric (excluding bifrontal), and posterior fossa involvement compared with unihemispheric and bifrontal. Factors that were moderately associated with higher mortality included intracranial pressure (ICP) above 20 mm Hg and Glasgow Coma Scale (GCS) score at presentation of 3 or 4. Upon multivariate analysis, the significant factors for mortality were bullet trajectory and pupillary response. Variables found to be significant for good functional outcome were admission GCS score greater than or equal to 5, pupillary reactivity, and bullet trajectory of unihemispheric or bifrontal. Factors moderately associated with good outcome included age of 35 years or younger, initial ICP 20 mm Hg or lower, and lack of transventricular trajectory. In the multivariate analysis, significant factors for good functional outcome were bullet trajectory and pupillary response, with age moderately associated with improved functional outcomes. The authors also propose a scoring system to estimate survival and functional outcome.

Conclusions

Age, pupils, GCS score, and bullet trajectory on CT scan can be used to determine likelihood of survival and good functional outcome. The authors advocate assessing patients based on these parameters rather than pronouncing a poor prognosis and withholding aggressive resuscitation based upon low GCS score alone.