Background. Decompressive craniectomy can be proposed in the management of severe traumatic brain injury. Current studies report mixed results, preventing any clear conclusions on the place of decompressive craniectomy in traumatology. Methods. The objective of this retrospective study was to evaluate the results of all decompressive craniectomies performed between 2005 and 2011 for refractory intracranial hypertension after severe traumatic brain injury. Sixty patients were included. Clinical parameters (Glasgow scale, pupillary examination) and radiological findings (Marshall CT scale) were analysed. Complications, clinical outcome, and early and long-term Glasgow Outcome Scale (GOS) were evaluated after surgery. Finally, the predictive value of preoperative parameters to guide the clinician's decision to perform craniectomy was studied. Results. Craniectomy was unilateral in 58 cases and the mean bone flap area was 100 cm2. Surgical complications were observed in 6.7% of cases. Mean followup was 30 months and a favourable outcome was obtained in 50% of cases. The initial Glasgow Scale was the only statistically significant predictive factor for long-term outcome. Conclusion. Despite the discordant results in the literature, this study demonstrates that decompressive craniectomy is useful for the management of refractory intracranial hypertension after severe traumatic brain injury.

The accumbofrontal fasciculus is an elective and specific projection from the orbitoprefrontal cortex. This fasciculus is part of a corticostriatothalamocortical loop and a putative target for deep-brain stimulation in the treatment of obsessive-compulsive disorder and major depression. The analysis of in vivo diffusion tractography, used today as a standard in the investigation of many brain disorders, could potentially take advantage of complementary anatomic correlations and functional extrapolations, as described in this study.

IntroductionDescription of a continuous hypertonic saline solution (HSS) infusion using a dose-adaptation of natremia in traumatic brain injured (TBI) patients with refractory intracranial hypertension (ICH).MethodsWe performed a single-center retrospective study in a surgical intensive care unit of a tertiary hospital. Fifty consecutive TBI patients with refractory ICH treated with continuous HSS infusion adapted to a target of natremia. In brief, a physician set a target of natremia adapted to the evolution of intracranial pressure (ICP). Flow of NaCl 20% was a priori calculated according to natriuresis, and the current and target natremia that were assessed every 4 hours.ResultsThe HSS infusion was initiated for a duration of 7 (5 to 10) (8 ± 4) days. ICP decreased from 29 (26 to 34) (31 ± 9) mm Hg at H0 to 20 (15 to 26) (21 ± 8) mm Hg at H1 (P < 0.05). Cerebral perfusion pressure increased from 61 (50 to 70) (61 ± 13) mm Hg at H0 up to 67 (60 to 79) (69 ± 12) mm Hg at H1 (P < 0.05). No rebound of ICH was reported after stopping continuous HSS infusion. Natremia increased from 140 (138 to 143) (140 ± 4) at H0 up to 144 (141 to 148) (144 ± 4) mmol/L at H4 (P < 0.05). Plasma osmolarity increased from 275 (268 to 281) (279 ± 17) mmol/L at H0 up to 290 (284 to 307) (297 ± 17) mmol/L at H24 (P < 0.05). The main side effect observed was an increase in chloremia from 111 (107 to 119) (113 ± 8) mmol/L at H0 up to 121 (117 to 124) (121 ± 6) mmol/L at H24 (P < 0.05). Neither acute kidney injury nor pontine myelinolysis was recorded.ConclusionsContinuous HSS infusion adapted to close biologic monitoring enables long-lasting control of natremia in TBI patients along with a decreased ICP without any rebound on infusion discontinuation.

Papillary tumors of the pineal region constitute a rare entity, with a difficult diagnosis, an uncertain prognosis, and a high risk of local recurrence; they must be treated by a combination of surgery and radiotherapy. The only identified prognostic factor is the complete or incomplete nature of surgical resection.