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22 Rescuing the injured brain – surgical trials in neurotrauma
  1. Peter Hutchinson
  1. Professor of Neurosurgery, NIHR Research Professor and Head of the Division of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge

Abstract

Peter holds an Honorary Consultant Neurosurgeon post at Addenbrooke’s Hospital. He is also Director of Clinical Studies at Robinson College, Cambridge. He has a general neurosurgical practice with a sub-specialist interest in the management of neuro-trauma, specifically head and traumatic brain injury. He has a research interest in acute brain injury, utilising multimodality monitoring technology (measurement of pressure, oxygenation and chemistry) to increase the understanding of the pathophysiology of brain injury. He also leads the international RESCUE studies evaluating the role of decompressive craniectomy in traumatic brain injury. He was awarded the Olivecrona Prize (the Nobel Prize for Neurosurgery in 2015) for his work on cerebral metabolism in acute brain injury).

He has co-authored over 300 publications (including NEJM, Lancet and Brain) and been lead applicant in over £7 m of grants (including MRC and NIHR). He is joint editor of the book “Head Injury – A Multidisciplinary Approach” and the Oxford Textbook of Neurological Surgery, the first edition of which is currently in preparation.

He is also Royal College of Surgeons Neurosurgical Specialty lead for clinical trials, Chair of the Academic Committee of the Society of British Neurological Surgeons, Secretary of the European Association of Neurosurgical Societies, Treasurer of the International Neurotrauma Society, Neurosurgical Representative on the NICE head guidelines development group and Chief Medical Officer for the Formula One British Grand Prix.

Brain trauma is the leading cause of death and disability in young adults. In Europe, 2.5 million people suffer a traumatic brain injury (TBI) each year, 1 million are admitted to hospital and 75 000 die. An estimated 7.7 million people live with a TBI-related disability. While advances in management including the introduction of advanced trauma life support, NICE head injury guidelines, and protocol driven therapy have improved outcome major gains are still needed in terms of increasing our understanding of the pathophysiology of this heterogeneous condition and defining and optimising treatment strategies. In the past there has been a failure to translate advances in pre-clinical studies into enhanced patient treatment despite many randomised controlled trials. We therefore need to better understand the pathophysiological mechanisms in humans and undertake improved clinical studies relevant to the heterogeneity of this condition.

The fundamental pathophysiology of TBI evolves from both primary insult (occurring at the ictus) and secondary insults (particularly hypoxia and hypotension). The result of both processes is brain swelling within the tight confines of the skull resulting in increase in intracranial pressure (ICP), reduction in cerebral blood flow, cerebral hypoxia, energy failure with cerebral oedema and further brain swelling culminating in poor outcome for the patient. The goal of intensive care and surgical treatment is to intercept this vicious cycle.

Novel approaches are required with the implementation of technology to improve our interrogation of the pathophysiology and to guide treatment. Such technology includes multimodality monitoring techniques (ICP, autoregulation, cerebral blood flow, oxygenation, and metabolism) and advanced imaging (MRI and PET). Clinical trial design requires refinement with randomised studies of medical and surgical interventions running in parallel with other approaches e.g. comparative effectiveness research. Overall, treatment protocols need to be flexible to meet the requirements of individual patients giving them the best chance of good quality survival. This talk will cover two fundamental areas of traumatic brain injury management – monitoring and surgical trials which now address a number of different neurotrauma pathologies.

Reference

  1. . Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ; RESCUEicp Trial Collaborators.Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med2016Sep 22;375(12):1119–30. doi:10.1056/NEJMoa1605215.

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