Leonardo Christiaan Welling

Below is a clarification note regarding the recently published letter in Lancet Neurology titled “Thank you very much, SYNAPSE-ICU.” We have received criticism for our letter and want to address any misunderstandings it may have caused. We want to clarify that we are the main advocates of intracranial monitoring, and any suggestion to the contrary is false. At no point in our letter did we state that the AMIB or any other society class representative did not recommend ICP monitoring. The editorial board of Lancet Neurology had to remove some excerpts from our letter due to word count constraints, but this does not change our message. As Rojas et al. state, Brazil is a big country with almost European dimensions, and medical conduct has several differences. We believe such differences cannot exist, especially concerning ICP monitoring. Such a privilege should not be for a few services but for the entire population. We aim to draw health managers' attention to the importance of using intracranial monitoring catheters, especially in the public health network. We believe every patient has the right to ICP monitoring, and we will not rest until this becomes a reality. Furthermore, we hope this clarification note will set the record straight and show our commitment to advocating for better healthcare. Below is the transcript originally sent to Lancet Neurology to clarify any disagreements. Thank you very much, SYNAPSE – ICU In underdeveloped countries, intracranial pressure monitoring may be considered a luxury item. Unfortunately, in the public health network, which covers a large portion of the population, the management of intracranial hypertension in acute neurological situations is practically based on radiological findings.[1] However, these findings do not present a direct correlation with the occurrence of intracranial hypertension. This fact has been known since the 1980s. Even more serious is knowing that it has been well established, for more than 60 years, that there is a direct relationship between intracranial hypertension and death. Nevertheless, studying the waveform's compliance is essential to predicting earlier brain changes.[1] [2] Many public and private health authorities have recently used The BEST Trip Trial as a theoretical and dogmatic basis for not including intracranial pressure monitoring technology in managing neurocritical patients in our country3. Despite being published in a high-impact journal, The Best Trip Trial study has significant limitations. This work was the object of various criticisms and raised controversies of all kinds.[4] The study was not designed to assess intracranial pressure monitoring; its objective was to analyze two approaches to the same problem: intracranial hypertension. Despite being a beautiful job, there were interpretation distortions by local managers, and it does not make sense that all non-invasive and invasive technology available nowadays is unused. Multimodal monitoring is recommended in critical care patients.[1] [2] The recent publication of SYNAPSE-ICU opens our horizons for local managers to include this technology as the minimum necessary for the care of the neurocritical patient. More important than diagnosing intracranial hypertension, knowing what to do with this parameter is what changes outcomes.[4] [5] We believe the monitoring register would be of value to neurocritical patients in several circumstances. Its advantages are affordability, efficiency, and simple and practical handling and it is used to better understand the natural history of the patient's disease. Many thanks to Lancet Neurology and the team involved in this work. Article published online: 11 December 2024 © 2024. Sociedade Brasileira de Neurocirurgia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Thieme Revinter Publicações Ltda. Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

"Letter to the Editor. Acute traumatic central cord syndrome: removing the occulted confounding variables" published on 14 Jun 2024 by American Association of Neurological Surgeons.

Cerebral vasospasm is determined as a temporary narrowing of cerebral arteries a few days after an aneurysmal subarachnoid hemorrhage. The onset of this vascular event usually evolves with new neurological deficits or progression of ischemic areas. The success of interventions to treat or revert this condition is not satisfying. In addition to cerebral vasospasm, early brain injury plays an important role as a contributor to subarachnoid hemorrhage’s mortality. In this sense, stellate ganglion block appears as an alternative to reduce sympathetic system’s activation, one of the main pathophysiological mechanisms involved in brain injury. Over the past few years, there is growing evidence that stellate ganglion block can contribute to decline patient morbidity from subarachnoid hemorrhage. Is it time to include this procedure as a standard treatment after aneurysm rupture?