A Modified Translaryngeal Tracheostomy Technique in the Neurointensive Care Unit. Rationale and Single-center Experience on 199 Acute Brain-damaged Patients Stefano Spina, MD,* Vittorio Scaravilli, MD,† Giovanni Cavenaghi, MD,‡ Dario Manzolini, MD,* Chiara Marzorati, MD,* Enrico Colombo, MD,§ Davide Savo, MD,§ Alessia Vargiolu, PhD,§ and Giuseppe Citerio, MD*§ Background: Brain-injured patients frequently require tracheostomy, but no technique has been shown to be the gold standard for these patients. We developed and introduced into standard clinical practice an innovative bedside translaryngeal tracheostomy (TLT) technique aided by suspension laryngoscopy (modi fied TLT). During this procedure, the endotracheal tube is left in place until the airway is secured with the new tracheostomy. This study assessed the clinical impact of this technique in brain-injured patients. Materials and Methods: This is a retrospective analysis of pro- spectively collected data from adult brain-injured patients who had undergone modi fied TLT during the period spanning from January 2010 to December 2016 at the Neurointensive care unit, San Gerardo Hospital (Monza, Italy). The incidence of intraprocedural compli- cations, including episodes of intracranial hypertension (intracranial pressure [ICP] > 20 mm Hg), was documented. Neurological, ven- tilatory, and hemodynamic parameters were retrieved before, during, and after the procedure. Risk factors for complications and intra- cranial hypertension were assessed by univariate logistic analysis. Data are presented as n (%) and median (interquartile range) for categorical and continuous variables, respectively. Results: A total of 199 consecutive brain-injured patients re- ceiving modified TLT were included. An overall 52% male in- dividuals who were 66 (54 to 74) years old and who had an admission Glasgow Coma Scale of 7 (6 to 10) were included in the cohort. Intracerebral hemorrhage (30%) was the most frequent diagnosis. Neurointensivists performed 130 (65%) of the procedures. Patients underwent tracheostomy 10 (7 to 13) days after intensive care unit admission. Short (ie, <2 min) and clinically uneventful increases in ICP > 20 mm Hg were observed in 11 cases. Overall, the procedure was associated with an increase in ICP from 7 (4 to 10) to 12 (7 to 18) mm Hg (P < 0.001). Compared with baseline, cerebral perfusion pressure (CPP), respiratory variables, and hemodynamics were unchanged during the procedure (P-value, not significant). Higher baseline ICP and core temperature were associated with an increased risk of complications and intracranial hypertension. Complication rates were low: 1 procedure had to be converted to a surgical tracheostomy, and 1 (0.5%) episode of minor bleeding and 5 (2.5%) of minor non-neurological complications were recorded. Procedures performed by intensivists did not have a higher risk of complications compared with those performed by ear, nose, and throat specialists. Conclusions: A modified TLT (by means of suspension lar- yngoscopy) performed by neurointensivists is feasible in brain- injured patients and does not adversely impact ICP and CPP. Key Words: tracheostomy, brain injury, intracranial hyper- tension, cerebral perfusion pressure (J Neurosurg Anesthesiol 2018;00:000–000) B rain-injured patients frequently require tracheostomy because of the requirement for prolonged airway protection, 1 but, up until now, no tracheostomy technique has been proven to be the gold standard for these patients. 2,3 Recently, percutaneous dilatational techniques (PDTs) have been introduced into routine clinical practice. 4,5 Compared with standard surgical trache- ostomy, PDTs do not require transport to the operation room and therefore remove the risks of transport-related complications. 6 Moreover, PDTs can be performed by Received for publication March 14, 2018; accepted July 17, 2018. From the *School of Medicine and Surgery, University of Milan-Bicocca; †Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan; ‡ENT–Head and Neck Surgery; and §Neurointensive Care Unit, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Italy. S.S. and V.S. contributed equally. G.C. and V.S.: contributed to the conception and design of the study. S.S., C.M., D.M., and A.V.: contributed to the acquisition and analysis of data for the work. V.S. and S.S.: performed the statistical analysis. V.S., S.S., and G.C.: wrote the first draft of the manuscript, with input from all the coauthors. A first and partial analysis of this study was presented at the ESICM LIVES 2016. An abstract has been published: “Tracheostomy in brain injured patients: a single center retrospective study on 170 consecutive patients” Intensive Care Medicine Experimental 2016, 4 (suppl 1):A130. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Stefano Spina, MD, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza 20900, Italy (e-mail: s.spina7@campus.unimib.it). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website, www.jnsa. com. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/ANA.0000000000000535 CLINICAL INVESTIGATION J Neurosurg Anesthesiol  Volume 00, Number 00, ’’ 2018 www.jnsa.com | 1 Copyright r 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. This paper can be cited using the date of access and the unique DOI number which can be found in the footnotes.