Traumatic brain injury is a leading cause of mortality and long-term disability worldwide. It encompasses a broad spectrum of conditions with pathophysiological heterogeneity. Clinical treatment practices are also heterogenous due to disparities in care between, and within, low- and high-income care settings. Extra-cranial injury, present in half of all patients with severe traumatic brain injury, often associated with high-energy trauma, can cause systemic organ dysfunction and exacerbate secondary brain injury. Preventing this through protocolized assessment and prompt resuscitation remain the focus of the initial phase of care. Neurocritical care management of traumatic brain injury is a complex and multifaceted process that requires continuous integration of intracranial and systemic physiological monitoring. Advances in multidimensional frameworks for the characterization of traumatic brain injury, including biomarkers and advanced neuroimaging, may help to individualize therapies. Challenges remain, healthcare inequalities in high-income countries are exacerbated by inadequate focus on low-energy falls in older patients and follow-up in mild traumatic brain injury. In this review, we summarize current approaches to the care of patients with moderate-to-severe injury, with particular emphasis on specialized neurocritical care, and discuss key areas of uncertainty and evolving practice.

Fever is a common complication in adults with acute brain injury and has consistently been associated with worse neurological outcomes and increased mortality. Whilst acute brain injury comprises a heterogenous group of pathologies, the need to mitigate against secondary brain injury is a unifying principle in their management, and targeted temperature control is a key component of a multi-modal neuroprotective strategy.The contemporary approach to temperature management within neurocritical care focuses on avoiding hyperthermia, maintaining normothermia and, in some cases, inducing hypothermia. Recent expert consensus guidance support the use of targeted temperature management with an emphasis on timely initiation, limitation of temperature variability, and avoidance of hyperthermia for the period of risk of secondary brain injury.In this article we aim to summarize the evidence for each of the key brain pathologies for which targeted temperature management is undertaken and provide an overview of the practical aspects involved in successfully delivering high-quality temperature control.

Supraphysiologic levels of oxygen could have potential adverse effects on the brain that may be dose and time dependent in patients with brain injury. We therefore aimed to assess whether exposure to excess supplemental oxygen, measured as time-weighted mean exposure to hyperoxemia, was associated with intensive care unit (ICU) mortality in patients with intracerebral hemorrhage (ICH). In this single-center retrospective cohort study, we included all patients admitted to our ICU with a diagnosis of primary spontaneous ICH. To provide a longitudinal measure of hyperoxemia exposure, we calculated the hyperoxemia dose, defined as the area under the partial pressure of oxygen in arterial blood (PaO2) time curve above the threshold PaO2 value of 100 mm Hg (13.3 kPa) divided by the number of hours of potential exposure. To provide consistent potential exposure windows and limit bias from informative censoring, nested subsets were created with progressively longer exposure periods (0–1 day, 0–2 days, 0–3 days, 0–4 days, 0–5 days, 0–6 days, 0–7 days). We used multivariable Cox regression, with hyperoxemia dose as a time-dependent covariate, to model ICU mortality. Admission ICH and Acute Physiology and Chronic Health Evaluation II scores were included as predictor covariables. A step-function extended Cox model was also fitted. Between September 2019 and July 2022, 275 patients met the inclusion criteria, with 24,588 arterial blood gas results available for analysis. The mean age was 57.19 years (± 13.99), 59.64

This review considers important aspects in the provision of anesthesia for endovascular neurosurgery. Subject literature was reviewed to include important publications which have influenced neuro-interventional practice alongside recent meta-analyses to provide a contemporaneous evidence-based review. The scope of endovascular neurosurgery and interventional neuro-radiology continues to expand. The advancement of catheter and imaging technologies, alongside the development of novel techniques, has allowed a minimally invasive endovascular approach to be applied to pathologies previously only treatable by open surgery, and to patients previously considered unsuitable for invasive surgical approaches. This has led to increasing complexity in both the procedures performed and the patients encountered in the neuro-radiology suite. An understanding of the technical aspects, physiological requirements, and potential problems relating to each procedure is required to facilitate close cooperation between the anesthesiologist and neuro-interventional team, to provide safe and effective care.

BACKGROUND:The World Health Organisation declared a coronavirus disease 2019 (COVID-19) pandemic on March 11, 2020. Following activation of the UK pandemic response, our institution began planning for admission of COVID-19 patients to the neurointensive care unit (neuro-ICU) to support the local critical care network which risked being rapidly overwhelmed by the high number of cases. This report will detail our experience of repurposing a neuro-ICU for the management of severely ill patients with COVID-19 while retaining capacity for urgent neurosurgical and neurology admissions.METHODS:We conducted a retrospective process analysis of the repurposing of a quaternary level neuro-ICU during the early stages of the COVID-19 pandemic in the United Kingdom. We retrieved demographic data, diagnosis, and outcomes from the electronic health care records of all patients admitted to the ICU between March 1, 2020 and April 30, 2020. Processes for increase in surge capacity, reduction in ICU demand, and staff redeployment and rapid training are reported.RESULTS:Over a 10-day period, total ICU capacity was increased by 21.7% (from 23 to 28 beds) while the capacity to provide mechanical ventilation was increased by 77% (from 13 to 23 beds). There were 30 ICU admissions of 29 COVID-19 patients between March 1 and April 30, 2020; median (range) length of ICU stay was 9.9 (1.3 to 32) days, duration of mechanical ventilation 11 (1 to 27) days, and ICU mortality rate 41.4%. There was a 44% reduction in urgent neurosurgical and neurology admissions compared with the same period in 2019.CONCLUSIONS:It is possible to repurpose a dedicated neuro-ICU for the management of critically ill non-neurological patients during a pandemic response, while maintaining access for urgent neuroscience referrals.

Changes in tumour 3′-deoxy-3′-[18F]fluorothymidine (FLT) uptake during concurrent chemo-radiotherapy in patients with non-small cell lung cancer (NSCLC) have been reported, at variable time points, in two pilot positron emission tomography (PET) studies. The aim of this study was to assess whether FLT changes occur early in response to radiotherapy (RT) without concurrent chemotherapy and whether such changes exceed test-retest variability.

SUZY STOKES, NICK S. KALSON, MARK EARL, ADAM G. WHITEHEAD, IAN TYRRELL-MARSH, HANNAH FROST, ANDREW DAVIES Clinical Education Centre, University Hospital of North Staffordshire, Stoke-on-Trent ST4 6QG, UK Manchester University Medical School and MARS—Manchester Altitude Research Society, The Medical School, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PL, UK Hope Hospital, Salford, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK Tel: 07814263092. Email: suzystokes@doctors.org.uk To whom correspondence should be addressed

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Thousands of young people travel to high altitude annually. Medical problems encountered range from relatively benign acute mountain sickness (AMS) to potentially fatal high altitude cerebral and pulmonary oedema.1 There is limited information on the incidence of these illnesses, or the varying presentations and outcome of children who succumb to them. We studied physiology and AMS incidence in tourist trekkers attempting the summit (Uhuru Peak) of Mount Kilimanjaro (5895 m). All subjects gave written informed consent and ethics approval was obtained from the Tanzanian Commission for Science and …

OBJECTIVE:To determine the incidence of acute mountain sickness (AMS), the frequency of summiting success, and the factors that affect these in trekkers on Kilimanjaro, one of the world's most summitted high-altitude peaks.METHODS:The study group comprised 312 trekkers attempting Mt Kilimanjaro summit by the Marango Route. Trekkers ascended over 4 or 5 days along a fixed ascent profile, stopping at 3 huts on ascent (2700 m, 3700 m, and 4700 m) before attempting the summit. Researchers were stationed at each hut for 16 days. Each night we measured heart rate, respiratory rate, blood pressure, oxygen saturation, and Lake Louise Score. We recorded the highest altitude that trekkers reached on the mountain.RESULTS:Of 181 complete sets of data, 111 (61%) trekkers reached the summit, and 139 (77%) developed AMS. Physiological results were not related to summit success. The incidence of AMS and summiting success were similar in those on the 4- or 5-day route. Trekkers on the 5-day route who used acetazolamide were less likely to develop AMS and more likely to summit than were those not taking acetazolamide (P = <.05); this difference was not present with trekkers on the 4-day route.CONCLUSIONS:The risk of developing AMS is high on Mt Kilimanjaro. Although taking an extra day to acclimatize with the use of acetazolamide did provide some protection against AMS, ideally trekkers need a more gradual route profile for climbing this mountain.

The I-allele rather than the D-allele of the human angiotensin converting enzyme (ACE) gene has been associated with high-altitude mountaineering success. We investigated whether the I-allele was associated with summit success, and also with AMS development, in altitude-naïve trekkers. Subjects ascended from 1,860 m to the summit over 4 days (n = 34, 'direct-profile') or 5 days (n = 82, 'slower-profile'). Proportionally more II direct-profile subjects were successful than ID or DD, although the difference was not significant (100% of II subjects, 52% ID and 43% DD, P = 0.09). There was no difference in success amongst subjects on the slower-profile (50% II, 45% ID and 58% DD, P = 0.54). There was a non-significant trend for increasing AMS scores in ID/DD subjects. Amongst tourist trekkers on Mt. Kilimanjaro the I-allele is not associated with summit success. No evidence is found to support an association between ACE genotype and AMS development.

Every year, an increasing number of people travel to high altitude and travellers with asthma are becoming more common in remote environments.1 It is well recognised that certain situations at high altitude, such as exercising in cold air, may provoke symptoms.2 However, the mountain environment offers a reduced pollutant and allergen load, potentially causing fewer exacerbations.3 Additionally, increased sympathetic tone and adrenocortical output caused by hypoxia counteract bronchospasm. Acetazolamide, used widely by trekkers for the prophylaxis of acute mountain sickness (AMS), has an additional benefit in patients with asthma of reducing airway hyperreactivity.4 To our knowledge, this is the first prospective …