Cerebral vasospasm (CVS) is one of the most critical factors associated with clinical outcomes of patients with subarachnoid hemorrhage (SAH). Clazosentan has been investigated worldwide as a prophylactic agent to prevent CVS. We evaluated a new CVS management protocol which included clazosentan. Consecutive 138 patients with SAH, hospitalized in our institution between January 2017 and December 2022, were included in this study. Baseline characteristics, clinical findings, and operative records were analyzed retrospectively. From May 2022, 10 mg/h clazosentan was co-administered with fasudil to all patients according to the indication in the Japanese label. Patients admitted before this date received the conventional combined protocol using the fasudil hydrochloride, nicardipine, and ozagrel. Eighteen (13.0%) patients received the new protocol during the CVS period (defined as day 1 up to day 14 after SAH onset). There were 54 (39.1%) elderly patients aged 75 years or older. Seventy-two (52.2%) patients underwent neurosurgical clipping, whereas 55 (39.9%) patients received endovascular coiling. Among the patients with new protocol, only one patient (5.6%) had symptomatic CVS, compared with 18 patients (15.0%) in those with conventional protocol. More patients who received the new protocol had fluid retention compared with control group (38.9% [7/18] vs. 8.3% [10/120]). Other results did not differ between the two groups. Clinical outcomes of the new protocol were comparable to those of conventional protocol. Clazosentan may simplify anti-vasospasm treatment. Fluid retention was a specific side-effect of clazosentan, which requires attention especially in the first half of the CVS period.

DuraGen is a widely used type I collagen matrix derived from bovine Achilles tendon that promotes fibroblast ingrowth and neovascularization. However, it remains unknown the time required for dura regeneration and reabsorption of the graft. We evaluate the histopathological characteristics of implanted DuraGen in humans across multiple time points. Patients who underwent a decompressive craniectomy and duraplasty with DuraGen at our institution between January 2020 and September 2021 were prospectively enrolled. At the time of the subsequent surgery, including cranioplasty, DuraGen and associated tissues removed from patients were sent for histopathological analysis. For each patient, time from index surgery to subsequent surgery was categorized into three groups: early (0–20 days), intermediate (21–30 days), and late (> 30 days). Baseline characteristics, primary disease, operative time, complication rate, and histopathological findings were compared between groups. A total of 28 patients were enrolled in the study. Seven specimens (25.0%) were collected within 20 days after craniectomy, 9 specimens (35.7%) between 21 and 30 days, and 12 specimens (39.3%) over 31 days. Histopathologically, implanted collagen matrix, erythrocyte infiltration, and fibrin layer decreased over time, whereas fibroblasts and endogenous collagen increased. Receiver operating characteristic analysis showed that the cut-off time post-implantation for presence of endogenous collagen was 34 days after DuraGen implantation (area under the curve = 0.810). We found that DuraGen was replaced by fibroblast-derived endogenous collagen as early as 34 days post-implantation. Although certain findings remain to be further validated, the present study substantiates DuraGen as a reliable substitute, with findings derived from clinical outcomes and histopathological changes.

Background: This study aimed to identify easily available prognostic factors in severe traumatic brain injury (TBI) patients undergoing craniotomy. Methods: We retrospectively analyzed the clinical characteristics (age, sex, Glasgow coma scale score, cause of TBI, and oral antithrombotic drug use), laboratory parameters (hemoglobin, sodium, C-reactive protein, D-dimer, activated partial thromboplastin time, prothrombin time-international normalized ratio, and glucose-potassium [GP] ratio), and neuroradiological findings of 132 patients who underwent craniotomy for severe TBI in our hospital between January 2015 and December 2021. The patients were divided into two groups: Those with fatal clinical outcomes and those with non-fatal clinical outcomes, and compared between the two groups. Results: The patients comprised 79 (59.8%) male and 53 (40.2%) female patients. Their mean age was 67 ± 17 years (range, 16–94 years). Computed tomography revealed acute subdural hematoma in 108 (81.8%) patients, acute epidural hematoma in 31 (23.5%), traumatic brain contusion in 39 (29.5%), and traumatic subarachnoid hemorrhage in 62 (47.0%). All 132 patients underwent craniotomy, and 41 eventually died. There were significant differences in the D-dimer, GP ratio, and optic nerve sheath diameter between the groups (all P < 0.01). Multivariate logistic regression analysis showed elevated GP ratio and D-dimer were associated with the death group (P < 0.01, P < 0.01, respectively). A GP ratio of >42 was the optimal cutoff value for the prediction of a fatal outcome of TBI (sensitivity, 85.4%; specificity, 51.1%). Conclusion: The GP ratio and D-dimer were significantly associated with poor outcomes of TBI. A GP ratio of >42 could be a predictor of a fatal outcome of TBI.