Effects of unilateral decompressive craniectomy on patients with unilateral acute post-traumatic brain swelling after severe traumatic brain injury

INTRODUCTION

Acute post-traumatic brain swelling (BS) is one of the pathological forms that need emergent treatment following traumatic brain injury. There is controversy about the effects of craniotomy on acute post-traumatic BS. The aim of the present clinical study was to assess the efficacy of unilateral decompressive craniectomy (DC) or unilateral routine temporoparietal craniectomy on patients with unilateral acute post-traumatic BS.

METHODS

Seventy-four patients of unilateral acute post-traumatic BS with midline shifting more than 5 mm were divided randomly into two groups: unilateral DC group (n = 37) and unilateral routine temporoparietal craniectomy group (control group, n = 37). The vital signs, the intracranial pressure (ICP), the Glasgow outcome scale (GOS), the mortality rate and the complications were prospectively analysed.

RESULTS

The mean ICP values of patients in the unilateral DC group at hour 24, hour 48, hour 72 and hour 96 after injury were much lower than those of the control group (15.19 +/- 2.18 mmHg, 16.53 +/- 1.53 mmHg, 15.98 +/- 2.24 mmHg and 13.518 +/- 2.33 mmHg versus 19.95 +/- 2.24 mmHg, 18.32 +/- 1.77 mmHg, 21.05 +/- 2.23 mmHg and 17.68 +/- 1.40 mmHg, respectively). The mortality rates at 1 month after treatment were 27% in the unilateral DC group and 57% in the control group (p = 0.010). Good neurological outcome (GOS Score of 4 to 5) rates 1 year after injury for the groups were 56.8% and 32.4%, respectively (p = 0.035). The incidences of delayed intracranial hematoma and subdural effusion were 21.6% and 10.8% versus 5.4% and 0, respectively (p = 0.041 and 0.040).

CONCLUSIONS

Our data suggest that unilateral DC has superiority in lowering ICP, reducing the mortality rate and improving neurological outcomes over unilateral routine temporoparietal craniectomy. However, it increases the incidence of delayed intracranial hematomas and subdural effusion, some of which need secondary surgical intervention. These results provide information important for further large and multicenter clinical trials on the effects of DC in patients with acute post-traumatic BS.

TRIAL REGISTRATION

ISRCTN14110527.

Effects of therapeutic mild hypothermia on patients with severe traumatic brain injury after craniotomy

PURPOSE

We investigated the effects of therapeutic mild hypothermia on patients with severe traumatic brain injury after craniotomy (TBI).

METHODS

Eighty patients with severe TBI after unilateral craniotomy were randomized into a therapeutic hypothermia group with the brain temperature maintained at 33 degrees C to 35 degrees C for 4 days, and a normothermia control group in the intensive care unit. Vital signs, intracranial pressure, serum superoxide dismutase level, Glasgow Outcome Scale scores, and complications were prospectively analyzed.

RESULTS

The mean intracranial pressure values of the therapeutic hypothermia group at 24, 48, and 72 hours after injury were much lower than those of the control group (23.49 +/- 2.38, 24.68 +/- 1.71, and 22.51 +/- 2.44 vs 25.87 +/- 2.18, 25.90 +/- 1.86, and 24.57 +/- 3.95 mm Hg; P = .000, .000, and .003, respectively). The mean serum superoxide dismutase levels of the therapeutic hypothermia group at days 3 and 7 were much higher than those of the control group at the same time point (533.0 +/- 103.4 and 600.5 +/- 82.9 vs 458.7 +/- 68.1 and 497.0 +/- 57.3 mug/L, respectively; P = .000). The percentage of favorable neurologic outcome 1 year after injury was 70.0% and 47.5%, respectively (P = .041). Complications, including pulmonary infections (57.5% in the therapeutic hypothermia group vs 32.5% in the control group; P = .025) were managed without severe sequelae.

CONCLUSIONS

Therapeutic mild hypothermia provides a promising way in the intensive care unit for patients with severe TBI after craniotomy.

Changes in intracranial pressure gradients between the cerebral hemispheres in patients with intracerebral hematomas in one cerebral hemisphere

BACKGROUND

Intracranial-pressure (ICP) monitoring is useful for patients with increased ICP following hemorrhagic stroke. In this study, the changes in pressure gradients between the two cerebral hemispheres were investigated after hemorrhagic stroke of one side, and after a craniotomy.

METHODS

Twenty-four patients with acute cerebral hemorrhages and intracerebral hematomas who exhibited mass effect and midline shift to the contralateral side on computed tomography were selected for this study. After admission, both sides of the cranium were drilled, and optical fiber sensors were implanted to monitor the brain parenchyma pressure (BPP) in both cerebral hemispheres. All patients underwent surgical hematoma evacuations. The preoperative and postoperative BPP data from both cerebral hemispheres were collected at various time points and compared pairwise.

RESULTS

There were statistically significant differences (P < 0.01) in the preoperative BPP values between the two hemispheres at three different time points. Differences in the BPP values between the two hemispheres at the time of surgery, and 24 and 48 h after surgery, were not statistically significant (P > 0.05). The posteroperative BPPs of both hemispheres were statistically significantly lower than preoperative recordings.

CONCLUSIONS

BPP sensors should be applied to the injured cerebral hemisphere, because this becomes the source of increased ICP. Hematoma evacuation surgery effectively decreases ICP and eliminates pressure gradients between the two cerebral hemispheres, consequently enabling brain shift correction.

Pre-hospital mild therapeutic hypothermia for patients with severe traumatic brain injury

BACKGROUND

We aimed to assess the effects of pre-hospital mild therapeutic hypothermia (MTH) on patients with severe traumatic brain injury (sTBI).

METHODS

Eighty-six patients with sTBI were prospectively enrolled into the pre-hospital MTH group and the late MTH group (initiated in hospital). Patients in the pre-hospital MTH group were maintained at a tympanic temperature of 33°C-35°C before admission and continued to be treated with a therapeutic hypothermia device for 4 days. Patients in the late MTH group were treated with the same MTH parameters. Intracranial pressure (ICP), complications and Glasgow Outcome Scale (GOS) scores were monitored.

RESULTS

ICP was significantly lower for patients in the pre-hospital MTH group 24, 48, and 72 h after treatment (17.38 ± 4.88 mmHg, 18.40 ± 4.50 mmHg, and 16.40 ± 4.13 mmHg, respectively) than that in the late MTH group (20.63 ± 3.00 mmHg, 21.80 ± 6.00 mmHg, and 18.81 ± 4.50 mmHg) (P < .05). The favorable prognosis (GOS scores 4-5) rate in the pre-hospital MTH group was higher tha n the late MTH group (65.1% vs. 37.2%, respectively; P < .05) without complications .

CONCLUSION

Pre-hospital MTH for patients with STBI can reduce ICP and improve neurological outcomes.

Noninvasive selective brain cooling by head and neck cooling is protective in severe traumatic brain injury

Therapeutic hypothermia is a promising treatment for patients with severe traumatic brain injury (TBI). We present here the results of a study in which noninvasive selective brain cooling (SBC) was achieved using a head cap and neckband. Ninety patients with severe TBI were divided into a normothermia control group (n=45) and a SBC group (n=45), whose brain temperature was maintained at 33-35 degrees C for 3 days using a combination of head and neck cooling. At 24, 48 and 72h after injury, the mean intracranial pressure (ICP) values of the patients who underwent SBC were lower than those of the normothermia controls (19.14+/-2.33, 19.72+/-1.73 and 17.29+/-2.07 mmHg, versus 23.41+/-2.51, 20.97+/-1.86, and 20.13+/-1.87 mmHg, respectively, P<0.01). There was a significant difference in the neurological recovery of the two groups at the 6-month follow-up after TBI. Good neurological outcome (Glasgow Outcome Scale score of 4 to 5) rates 6 months after injury were 68.9% for the SBC group, and 46.7% for the control group (P<0.05). There were no complications resulting in severe sequelae. In conclusion, the noninvasive SBC described here is a safe method of administering therapeutic hypothermia, which can reduce ICP and improve prognosis without severe complications in patients with severe TBI.

Thrombocytopenia after therapeutic hypothermia in severe traumatic brain injury

OBJECTIVE

To investigate the clinical characteristics and significance of thrombocytopenia after therapeutic hypothermia in severe traumatic brain injury (TBI).

METHODS

Ninety-six inpatients with severe brain injury were randomized into three groups: SBC (selective brain cooling) group (n=24), MSH (mild systemic hypothermia) group (n=30), and control (normothermia) group (n=42). The platelet counts and prognosis were retrospectively analyzed.

RESULTS

Thrombocytopenia was present in 18 (75%), 23 (77%) and 15 (36%) patients in SBC group, MSH group and control group, respectively (P<0.01). Thrombocytopenia, in which the minimum platelet count was seen 3 days after hypothermia, showed no significant difference between SBC and MSH group (P>0.05). Most platelet counts (37 cases, 90%) in hypothermia group were returned to normal level after 1 to 2 days of natural rewarming. The platelet count in SBC group reduced by 16%, 27% and 29% at day 1, 3 and 5 respectively compared with the baseline value. Good recovery (GOS score 4-5) rate of thrombocytopenia 1 year after injury for hypothermia group (17 cases, 37%) was significantly lower than that of control group (P<0.01).

CONCLUSIONS

Therapeutic hypothermia increases the incidence of thrombocytopenia in severe TBI, and patients with thrombocytopenia after therapeutic hypothermia are associated with unfavorable neurological prognosis.

Therapeutic effect of mild hypothermia on severe traumatic head injury

OBJECTIVE

To investigate the therapeutic effect of mild hypothermia on severe traumatic brain injury.

METHODS

Eighty-six in-patients with severe traumatic brain injury treated ordinarily were consecutively randomized into two groups: a hypothermia group (n=43) and a normothermia group (the control group, n=43). In the hypothermia group, the core temperature (i.e., nasopharyngeal or brain temperature) of the patient was reduced to and maintained at 33-35 degrees C with a systemic cooling blanket. Natural rewarming began after 3-5 days (mean: 4.3 days) of hypothermia treatment. In the control group, the patient received no hypothermia treatment. The vital sign, extradural pressure and serum superoxide dismutase were observed and measured during treatment, and the complications as well as the Glasgow outcome scale were evaluated at 2 years after injury.

RESULTS

The mean extradural pressure in the hypothermia group (27.38 mm Hg +/- 4.88 mm Hg at 24 hours, 29.40 mm Hg +/- 4.50 mm Hg at 48 hours and 26.40 mm Hg +/- 4.13 mm Hg at 72 hours after injury) was much lower than that in the control group (32.63 mm Hg +/- 3.00 mm Hg, 34.80 mm Hg +/- 6.00 mm Hg and 31.81 mm Hg +/- 4.50 mm Hg respectively at 24, 48 and 72 hours, P<0.05). The mean serum superoxide dismutase levels in the hypothermia group on days 3 and 7 (583.7 microg/L +/- 99.6 microg/L and 699.4 microg/L +/- 217.3 microg/L, respectively) were much higher than those in the control group at the same time period (446.6 microg/L +/- 79.5 microg/L and 497.1 microg/L +/- 101.2 microg/L, respectively, P<0.01). The recovery rates at 2 years after injury were 65.1% in the hypothermia group and 37.2% in the control group (P<0.05). The mortality rates were 25.6% in the hypothermia group and 51.2% in the control group (P<0.05). The complications, including pulmonary infections, thrombocytopenia (platelet count < 100 x 10(9)/L), hemorrhage in the digestive tract, electrolyte disorders and renal malfunction, were managed without severe sequelae.

CONCLUSIONS

Mild hypothermia is a safe and effective therapeutic method, which can lower the extradural pressure, increase the serum superoxide dismutase and improve the neurological outcomes without severe complications in the patients with severe traumatic brain injury.