Background Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. Methods The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. Results The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. Conclusions In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Traumatic supra- and infra-tentorial extradural hematoma (TSIEDH) is a rare lesion constituting <2% of all extradural hematomas. There are only a few published articles about TSIEDH. This study included three patients with TSIEDH who were treated and operated at Dr. Soetomo General Hospital, Surabaya, Indonesia, from August 2015 to July 2016. Two patients sustained injuries in traffic accidents and one patient was injured by fall. The male to female ratio was 1:2. Glasgow Coma Scale (GCS) score ≤8 was present in one and GCS score of 9–12 was present in two patients. The brain computed tomography scan verified linear fracture of occipital bone in one and linear fracture of occipital bone with lambdoid suture separation in two patients. Early diagnosis and early surgical intervention of TSIEDH are imperative because the deterioration of TSIEDH is sudden and quick. We presented our experience in treating patients with TSIEDH in Dr. Soetomo General Hospital, Surabaya, Indonesia.

Background: MLC601 is a natural product formulation from Chinese medicine that is extensively studied in ischemic stroke. Traumatic brain injury (TBI) shares pathophysiological mechanisms with ischemic stroke, yet there are few studies on the use of MLC601 in treating TBI. This Indonesian pilot study aimed to investigate clinical outcomes of MLC601 for TBI. Methods: This randomized controlled trial included subjects with nonsurgical moderate TBI allocated into two groups: with and without MLC601 over three months in addition to standard TBI treatment. Clinical outcomes were measured by the Glasgow Outcome Scale (GOS) and Barthel Index (BI) observed upon discharge and at months (M) 3 and 6. Results: Thirty-two subjects were included. The MLC601 group (n = 16) had higher GOS than the control group (n = 16) at all observation timepoints, though these differences were not statistically significant (p = 0.151). The BI values indicated a significant improvement for the MLC601 group compared to the control group at M3 (47.5 vs. 35.0; p = 0.014) and at M6 (67.5 vs. 57.5; p = 0.055). No adverse effects were associated with MLC601 treatment. Conclusion: In this cohort of nonsurgical moderate TBI subjects, MLC601 showed potential for a positive effect on clinical outcome with no adverse effects.

Background: The maternal deaths due to obstetrical cases declined, but the maternal deaths that caused by nonobstetrical cases still increase. The study reported that traumatic cases in pregnancy are the highest causes of mortality in pregnancy (nonobstetrical cases) in the United States. Another study reported that 1 in 12 pregnant women that experienced traumatic accident and as many as 9.1% of the trauma cases were caused by traumatic brain injury (TBI). The female sex hormone has an important role that regulates the hemodynamic condition. Anatomical and physiological changes during pregnancy make the examination, diagnosis, and treatment of TBI different from non-pregnant cases. Therefore, it is very important to lead the algorithm for each institution based on their own resources. Case Series: A 37-year-old woman with a history of loss of consciousness after traffic accident. She rode a motorbike then hit the car. She was referred at 18 weeks' gestation. Glasgow Coma Scale (GCS) E₁V₁M₄, isochoric of the pupil, reactive to the light reflex, and right-sided hemiparesis. The non-contrast head computed tomography (CT) scan revealed subdural hematoma (SDH) in the left frontal-temporal-parietal region, SDH of the tentorial region, burst lobe intracerebral hemorrhage, and cerebral edema. There was not a fetal distress condition. The next case, a 31 years old woman, in 26 weeks gestation, had a history of unconscious after motorcycle accident then she fell from the height down to the field about 3 m. GCS E₁V₁M₃, isochoric of the pupil, but the pupil reflex decreased. Noncontrast CT scan revealed multiple contusion, subarachnoid hemorrhage, and cerebral edema. She had a good fetal condition. Discussion: We proposed the algorithm of TBI in pregnancy that we already used in our hospital. The main principle of the initial management must be resuscitating the mother and that also the maternal resuscitation. The primary and secondary survey is always prominent of the initial treatment. Conclusion: The clinical decision depends on the condition of the fetal, the surgical lesion of the intracranial, and also the resources of the neonatal intensive care unit in our hospital.

Introduction: A head fixation device containing pins is common equipment used in neurosurgical procedures. Previous reports analysed some of the complications associated with the application of this device for adults and children, even the indications for the use in pediatric are not well defined. Case presentation: An 11-year-old girl diagnosed with non-communicating hydrocephalus, caused by posterior fossa tumor. During the surgery, complications were found in the form of acute epidural hematoma due to head fixation pins. So, the operation was stopped. Emergent CT scan was carried out and showed a bilateral skull fracture and a massive right-sided epidural hematoma. An emergency craniotomy for clot removal was performed and five days later, a second surgery was carried out uneventfully for the residual tumor. The patient fully recovered after the second surgery. Discussion: Complications due to the use of a pin head fixation are easier to occur in pediatric patients, because the bones are thinner and need more carefull strategy when pinning. With promp identification of any complications and earlier treatment, the good outcome will be achieved. We compared our case report with published literature in order to suggest the way to prevent this complication. Conclusion: Skull fractures and associated epidural hematomas in pediatric patients need to be considered as possible complications of the pin-type head fixation application. The head fixation devices in pediatric need to be used with great caution and knowing the risk factors, safe technique for application and management of complications will prevent worse outcome. Highlights:

Background: Mortality predictions following traumatic brain injury (TBI) may be improved by including genetic risk in addition to traditional prognostic variables. One promising target is the gene coding for brain-derived neurotrophic factor (BDNF), a ubiquitous neurotrophin important for neuronal survival and neurogenesis. Methods: A total of seven publications pertaining to BDNF in the study of traumatic head injury were included and reviewed. The majority of patients were male, that is, 483 (83.85%) patients, compared to 93 (16.15%) female patients. The median length of follow-up was 6 months (3 days–12 months). Measurement of the patient’s initial condition was carried out by measuring the initial GCS of the patient at the time of admission across the five studies being 6.5. The median CSF BDNF levels in the unfavorable group being 0.2365 (0.19–0.3119) ng/ml, from favorable group which was 0.20585 (0.17–0.5526) ng/ml. The median serum BDNF level in the unfavorable group being 3.9058 (0.6142–13.0) ng/ml, from favorable group which was 4.3 (0.6174–23.3) ng/ml. Results: Six studies reported on the sex distribution of patients, the majority of patients were male, that is, 483 (83.85%) patients, compared to 93 (16.15%) female patients. Six studies reported the number of patients per outcome group. The comparison of the number of patients in the two groups was quite balanced with the number of patients in the good group as many as 269 patients (55.5%) and the number of patients in the unfavorable group as many as 216 patients (44.5%). Measurement of the patient’s initial condition was carried out by measuring the patient’s initial GCS at the time of admission. It was reported in five studies, with the overall mean baseline GCS across five studies being 6.5 (3.2–8.8). Measurement of patient outcome was carried out by several methods, two studies used Glasgow Outcome Scale, Glasgow Outcome Scale Extended was used in two studies, and five studies used survival as a patient outcome measure. The patient’s BDNF level was measured in CSF and/or serum. A total of four studies measuring BDNF CSF levels and serum BDNF levels. Measurement of BDNF levels in TBI patients conducted on patients in seven literatures showed that there were differences in the trend of BDNF levels from CSF sources and serum sources. Measurement of CSF BDNF levels CSF BDNF levels was reported in two of the seven literatures, with the median CSF BDNF level in the unfavorable group being 0.2365 (0.19–0.3119) ng/ml. CSF BDNF levels were higher than the median in the preferred group, which was 0.20585 (0.17–0.5526) ng/ml. The results of the analysis from three other literatures stated that there was a tendency for lower CSF BDNF levels in the preferred group. Serum BDNF levels were reported in two of the seven literatures, with the median serum BDNF level in the unfavorable group being 3.9058 (0.6142–13.0) ng/ml. This serum BDNF level was lower than the median in the preferred group, which was 4.3 (0.6174–23.3) ng/ml. The results of the analysis of four literatures reporting serum BDNF stated that there was a tendency for lower serum BDNF levels in the poor group. A risk assessment of bias for each study was performed using ROBINS-I because all included studies were non-RCT studies. Overall the results of the risk of bias analysis were good, with the greatest risk of confounding bias and outcome bias. Conclusion: Serum BDNF levels were found to be lower in the unfavorable group than in the favorable group. This is associated with an increase in autonomic function as well as a breakdown of the blood–brain barrier which causes a decrease in serum BDNF levels. Conversely, CSF BDNF levels were found to be higher in the unfavorable group than in the favorable group. This is associated with an increase in the breakdown of the blood–brain barrier which facilitates the transfer of serum BDNF to the brain, leading to an increase in CSF BDNF levels.