Robotic external ventricular drain placement for acute neurosurgical care in low-resource settings: feasibility considerations and a prototype design

OBJECTIVE
Emergency neurosurgical care in lower-middle-income countries faces pronounced shortages in neurosurgical personnel and infrastructure. In instances of traumatic brain injury (TBI), hydrocephalus, and subarachnoid hemorrhage, the timely placement of external ventricular drains (EVDs) strongly dictates prognosis and can provide necessary stabilization before transfer to a higher-level center of care that has access to neurosurgery. Accordingly, the authors have developed an inexpensive and portable robotic navigation tool to allow surgeons who do not have explicit neurosurgical training to place EVDs. In this article, the authors aimed to highlight income disparities in neurosurgical care, evaluate access to CT imaging around the world, and introduce a novel, inexpensive robotic navigation tool for EVD placement.

METHODS
By combining the worldwide distribution of neurosurgeons, CT scanners, and gross domestic product with the incidence of TBI, meningitis, and hydrocephalus, the authors identified regions and countries where development of an inexpensive, passive robotic navigation system would be most beneficial and feasible. A prototype of the robotic navigation system was constructed using encoders, 3D-printed components, machined parts, and a printed circuit board.

RESULTS
Global analysis showed Montenegro, Antigua and Barbuda, and Seychelles to be primary candidates for implementation and feasibility testing of the novel robotic navigation system. To validate the feasibility of the system for further development, its performance was analyzed through an accuracy study resulting in accuracy and repeatability within 1.53 ± 2.50 mm (mean ± 2 × SD, 95% CI).

CONCLUSIONS
By considering regions of the world that have a shortage of neurosurgeons and a high incidence of EVD placement, the authors were able to provide an analysis of where to prioritize the development of a robotic navigation system. Subsequently, a proof-of-principle prototype has been provided, with sufficient accuracy to target the ventricles for EVD placement.

Factors Explaining Quality of Life among People with Moderate to Severe Traumatic Brain Injury in Bangladesh: A Cross-Sectional Study

Traumatic brain injury leads to mortality and disability with consequences for the poor quality of life of people. Little study regarding the quality of life of people with traumatic brain injury in Bangladesh exists. This cross-sectional study aims to examine the quality of life and its influencing factors among people with moderate to severe traumatic brain injury. The participants were 249 people with moderate to severe traumatic brain injury, and their caregivers recruited from three public hospitals in Bangladesh. Data were collected through questionnaires including socio-demographic, the Injury Related Illness and Injury Severity Score questionnaire, the Charlson Comorbidity Index, the Modified Barthel Index, the Patients Health Questionnaire-9, the MOS-Social Support Survey, the Quality of Life after Brain Injury (QOLIBRI), the caregiver socio-demographic, and the Caregiver Preparedness Scale. Data were analyzed using descriptive statistics, Pearson’s correlation test, and stepwise multiple regression model.
Results showed that majority of the people reported a poor quality of life. Stepwise multiple regression analysis revealed that social support, caregiver preparedness, depression, and income, were significant factors and could explain 37% variance of quality of life. To improve the quality of life among people with traumatic brain injury, nurses should seek significant resources to support them, perform emotional support to prevent depression and prepare their caregivers with knowledge and proper skills for patients’ care. Eventually, they can have healthy transition and obtain desirable health outcomes with good quality of life.

Towards integration of transcranial Doppler in the management of severe TBI in LICs and LMICs: A cohort retrospective study

Background
Medical first-line management to fight against raised intracranial pressure due to severe TBI in LICs and LMICs is still precarious, especially with the lack of means for adequate monitoring of intracranial pressure.

Objective
In the cohort retrospective study, we aimed to show if the TCD could have an impact on decision-making to operate and on the GOS.

Methods
Patients treated at bi-institutional between March 2017 and July 2019, were included if they had Moderate to Severe TBI treated surgically. Variables associated with the outcome were tested using uni and multivariable analyses.

Results
One hundred and thirty-six TBI patients were admitted for management during the study period, 21 and 44 were excluded respectively because they were managed medically only, and were benign trauma. Seventy-one(71) patients were included in the final analysis. They had a mean age of 44.27 years old (+/− 15.99) at diagnosis and there was a male predominance (n = 59, 83,1%). 52(73.2%) of them benefited from TCD. The mean time between admission and the surgery in a cohort of patients from TCD monitoring was 6 h ± 4 vs 8 h ± 3 (P = 0.003). The mean GOS in the cohort group with non-TCD was 4,7 ± 1,1 versus 4,3 ± 1,1(P = 0.047)in the non-TCD cohort group. The paired test revealed statically significantly positive in the use of TCD for Severe TBI, Z = -3.859, P = 0.044 with a median effect (r = 0.23).

Conclusion
TCD has an impact on the early decision to go for DC and has a median effect on GOS.

Implementation of the infrascanner in the detection of post-traumatic intracranial bleeding: A narrative review

Introduction
Infrascanner is a portable and easy-to-use device that functions based on near infrared spectroscopy and can be utilized in prehospitalary and hospitalary environments and has risen as a promising resort for the detection of potentially lethal intracranial hemorrhages, especially in low-and-middle income countries where access to a tomographer is limited.

Results
The reviewed articles showed that the Infrascanner has a sensitivity that ranges from 68.7% to 100% and a specificity that ranges from 50.43% to 95.5% for intracranial bleedings.

Conclusions
The device has shown promising results in the detection of intracranial bleeding and has great potential for its applicability, especially in low- and middle-income countries. More studies are needed for the validation of its diagnostic accuracy and its correlation to the CT scan.

Emergency Department Outcome of Patients with Traumatic Brain Injury – A Retrospective Study from Pakistan

Introduction: Traumatic brain injury (TBI) is a leading cause of global morbidity and mortality in both adults and children. As with other severe injuries, the outcome of TBIs is also gravely related to the quality of emergency care. Effective emergency care significantly contributes to reduced morbidity and mortality. This study was ensued to evaluate the characteristics of TBIs in Pakistan and their outcomes in the emergency department (ED).

Methods: This retrospective review included records of all TBI patients seen in the Neurosurgical ED of Jinnah Postgraduate Medical Centre, Karachi, Pakistan from 1st September 2019 till 7th December 2019.

Results: During the study period, 5,546 patients with TBI were seen in the ED; an estimated 56.5 patients per day. There were 4,054 (73.1%) male and 1,492 (26.9%) female patients. Most of these (26%) were of age <10 years. The most common culprit of TBI was road traffic accidents (RTAs) (n=2,163; 39%) followed by accidental fall (n=1,785; 32.2%). Head injury was mostly mild (n=4,034; 72.8%) and only 265 (4.7%) had a severe injury. Only 10% (n=549) patients were admitted for further treatment, 16% were managed in the ED then discharged, and 67% were immediately discharged from the ED after the first examination and necessary management. The ED mortality rate of TBIs was 2.2% (n=123/5,546) in our study. All of these cases had severe head injuries.

Conclusion: Major culprits of TBI are RTAs and accidental falls. TBIs are mostly mild-to-moderate and the ED mortality rate is low.

Neurotrauma Registry Implementation in Colombia: A Qualitative Assessment

Objectives Latin America is among several regions of the world that lacks robust data on injuries due to neurotrauma. This research project sought to investigate a multi-institution brain injury registry in Colombia, South America, by conducting a qualitative study to identify factors affecting the creation and implementation of a multi-institution TBI registry in Colombia before the establishment of the current registry.

Methods Key informant interviews and participant observation identified barriers and facilitators to the creation of a TBI registry at three health care institutions in this upper-middle-income country in South America.

Results The study identified barriers to implementation involving incomplete clinical data, limited resources, lack of information and technology (IT) support, time constraints, and difficulties with ethical approval. These barriers mirrored similar results from other studies of registry implementation in low- and middle-income countries (LMICs). Ease of use and integration of data collection into the clinical workflow, local support for the registry, personal motivation, and the potential future uses of the registry to improve care and guide research were identified as facilitators to implementation. Stakeholders identified local champions and support from the administration at each institution as essential to the success of the project.

Conclusion Barriers for implementation of a neurotrauma registry in Colombia include incomplete clinical data, limited resources and lack of IT support. Some factors for improving the implementation process include local support, personal motivation and potential uses of the registry data to improve care locally. Information from this study may help to guide future efforts to establish neurotrauma registries in Latin America and in LMICs.

Decompressive craniotomy: an international survey of practice

Background
Traumatic brain injury (TBI) and stroke have devastating consequences and are major global public health issues. For patients that require a cerebral decompression after suffering a TBI or stroke, a decompressive craniectomy (DC) is the most commonly performed operation. However, retrospective non-randomized studies suggest that a decompressive craniotomy (DCO; also known as hinge or floating craniotomy), where a bone flap is replaced but not rigidly fixed, has comparable outcomes to DC. The primary aim of this project was to understand the current extent of usage of DC and DCO for TBI and stroke worldwide.

Method
A questionnaire was designed and disseminated globally via emailing lists and social media to practicing neurosurgeons between June and November 2019.

Results
We received 208 responses from 60 countries [40 low- and middle-income countries (LMICs)]. DC is used more frequently than DCO, however, about one-quarter of respondents are using a DCO in more than 25% of their patients. The three top indications for a DCO were an acute subdural hematoma (ASDH) and a GCS of 9-12, ASDH with contusions and a GCS of 3-8, and ASDH with contusions and a GCS of 9-12. There were 8 DCO techniques used with the majority (60/125) loosely tying sutures to the bone flap. The majority (82%) stated that they were interested in collaborating on a randomized trial of DCO vs. DC.

Conclusion
Our results show that DCO is a procedure carried out for TBI and stroke, especially in LMICs, and most commonly for an ASDH. The majority of the respondents were interested in collaborating on a is a future randomized trial.

Epidemiology of Traumatic Brain Injury in Georgia: A Prospective Hospital-Based Study

Purpose: Traumatic brain injury (TBI) is one of the major causes of morbidity and mortality worldwide, disproportionally affecting low- and middle-income countries (LMICs). Epidemiological characteristics of TBI at a national level are absent for most LMICs including Georgia. This study aimed to establish the registries and assess causes and outcomes in TBI patients presenting to two major trauma hospitals in the capital city –Tbilisi.
Patients and Methods: The prospective observational study was conducted at Acad. O. Gudushauri National Medical Center and M. Iashvili Children’s Central Hospital from March, 1 through August, 31, 2019. Patients of all age groups admitted to one of the study hospitals with a TBI diagnosis were eligible for participation. Collected data were uploaded using the electronic data collection tool –REDCap, analyzed through SPSS software and evaluated to provide detailed information on TBI-related variables and outcomes using descriptive statistics.
Results: Overall, 542 hospitalized patients were enrolled during the study period, about 63% were male and the average age was 17.7. The main causes of TBI were falls (58%) and struck by or against an object (22%). The 97% suffered from mild TBI (GCS 13– 15). Over 23% of patients arrived at the hospital more than 1 hour after injury and 25% after more than 4-hours post-injury. Moderate and severe TBI were associated with an increased hospital length of stay. Mortality rate of severe TBI was 54%.
Conclusion: This study provides important information on the major epidemiological characteristics of TBI in Georgia, which should be considered for setting priorities for injury management

Traumatic Brain Injury in Mumbai: A Survey of Providers along the Care Continuum

Introduction:
Traumatic brain injury (TBI) represents a significant burden of a global disease, especially in low- and middle-income countries (LMICs) such as India. Efforts to curb the impact of TBI require an appreciation of local factors related to this disease and its treatment.

Methods:
Semi-structured qualitative interviews were administered to paramedics, anesthesiologists, general surgeons, and neurosurgeons in locations throughout Mumbai from April to May 2018. A thematic analysis with an iterative coding was used to analyze the data. The primary objective was to identify provider-perceived themes related to TBI care in Mumbai.

Results:
A total of 50 participants were interviewed, including 17 paramedics, 15 anesthesiologists, 9 general surgeons, and 9 neurosurgeons who were involved in caring for TBI patients. The majority of physicians interviewed discussed their experiences in public sector hospitals (82%), while 12% discussed private sector hospitals and 6% discussed both. Four major themes emerged: Workforce, equipment, financing care, and the family and public role. These themes were often discussed in the context of their effects on increasing or decreasing complications and delays. Participants developed adaptations when managing shortcomings in these thematic areas. These adaptations included teamwork during workforce shortages and resource allocation when equipment was limited among others.

Conclusions:
Workforce, equipment, financing care, and the family and public role were identified as major themes in the care for TBI in Mumbai. These thematic elements provide a framework to evaluate and improve care along the care spectrum for TBI. Similar frameworks should be adapted to local contexts in urbanizing cities in LMICs.

Decompressive Craniectomy in Traumatic Brain Injury: An Institutional Experience of 131 Cases in Two Years

Decompressive craniectomy (DC) effectively reduces intracranial pressure (ICP), but is not considered to be a first-line procedure. We retrospectively analyzed sociodemographic, clinical, and surgical characteristics associated with the prognosis of patients who underwent DC to treat traumatic intracranial hypertension (ICH) at the Restauração Hospital (HR) in Recife, Brazil between 2015 and 2016, and compared the clinical features with surgical timing and functional outcome at discharge. The data were collected from 131 medical records in the hospital database. A significant majority of the patients were young adults (age 18-39 years old; 75/131; 57.3%) and male (118/131; 90.1%). Road traffic accidents, particularly those involving motorcycles (57/131; 44.5%), were the main cause of the traumatic event. At initial evaluation, 63 patients (48.8%) were classified with severe traumatic brain injury (TBI). Pupil examination showed no abnormalities for 91 patients (71.1%), and acute subdural hematoma was the most frequently observed lesion (83/212; 40%). Glasgow Outcome Scale (GOS) score was used to categorize surgical results and 51 patients (38.9%) had an unfavorable outcome. Only the Glasgow Coma Scale (GCS) score on admission (score of 3-8) was more likely to be associated with unfavorable outcome (p-value = 0.009), indicating that this variable may be a determinant of mortality and prognostic of poor outcome. Patients who underwent an operation sooner after injury, despite having a worse condition on admission, presented with clinical results that were similar to those of patients who underwent surgery 12 h after hospital admission. These results emphasize the importance of early DC for management of severe TBI. This study shows that DC is a common procedure used to manage TBI patients at HR.