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Kumarasamy S, Garg K, Singh PK, Satyarthee GD, Agrawal D. Cisternostomy as an Adjuvant or Standalone Approach for Management of Traumatic Brain Injury: A Systematic Review and Network Meta-Analysis. World Neurosurg 2024; 189:410-417.e4. [PMID: 38925245 DOI: 10.1016/j.wneu.2024.06.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of morbidity in all age groups worldwide. Decompressive craniectomy (DC) is a salvage procedure in patients with TBI. The outcome and quality of life following DC is questionable. Basal cisternostomy (BC) has been proposed to reduce edema and lead to brain relaxation. It was initially used as an adjunct in TBI patients, thereby improving outcomes. With gaining popularity among neurosurgeons, BC was used as a standalone approach in TBI patients. This network meta-analysis aims to analyze the role of BC either as an adjunct or as a standalone approach in managing TBI patients. METHODS A comprehensive search of electronic databases (PubMed and SCOPUS) was performed using the search strategy using the field terms and medical subheading terms (MeSH Terms) to retrieve studies describing the role of BC in patients with TBI either as an adjunct with DC or standalone treatment and their outcome. RESULTS Thirty-one articles were selected for full-text review and 18 articles were selected for the final analysis. BC alone group was found to have minimum in-hospital mortality (odds ratio [OR], 0.348; 95% credible interval [CrI], 0.254 to 0.477) followed by DC combined with BC group (OR, 0.645; 95% CrI, 0.476 to 0.875). DC combined with the BC group was found to have a minimum duration of mechanical ventilation (OR, 0.114; 95% CrI, 0.005 to 2.451) followed by the BC alone group (OR, 0.604; 95% CrI, 0.024 to 15.346). DC combined with the BC group were found to have the maximum Glasgow Outcome Scale score (OR, 1.661; 95% CrI, 0.907 to 3.041) followed by the BC alone group (OR, 1.553; 95% CrI, 0.907 to 3.041). CONCLUSIONS Our analysis showed that BC alone was associated with lower in-hospital mortality rates in TBI patients. DC with BC had decreased the requirement of mechanical ventilation. However, larger multi-centric studies from other parts of the world are required to confirm these findings.
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Affiliation(s)
- Sivaraman Kumarasamy
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India.
| | - Pankaj Kumar Singh
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Guru Dutta Satyarthee
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
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Gatos C, Fotakopoulos G, Georgakopoulou VE, Spiliotopoulos T, Sklapani P, Trakas N, Kalogeras A, Fountas KN. Bone graft absorption complication following cranioplasty: A retrospective institutional study. MEDICINE INTERNATIONAL 2024; 4:32. [PMID: 38680945 PMCID: PMC11046264 DOI: 10.3892/mi.2024.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/15/2024] [Indexed: 05/01/2024]
Abstract
The aim of the present retrospective study was to confer the factors that are related to bone graft absorption and affect the outcomes of patients following cranioplasty (CPL). The present retrospective study includes cases of patients that underwent CPL between February, 2013 and December, 2022. All participants had a follow-up period of 1 to 10 years from the day of discharge from the hospital. In total, 116 (62.3%) of the 186 patients that underwent decompressive craniectomy (DC) were enrolled in the present study for CPL. A total of 109 (93.9%) patients were included in group A, and 7 (6.0%) patients were included in group B. On the whole, the results of the present study suggest that a CPL after 2.5-7.7 months of DC increases the possibility of bone absorption.
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Affiliation(s)
- Charalampos Gatos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | | | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Adamantios Kalogeras
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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3
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Mutlucan UO, Orhun Ö, Özcan-Ekşi EE, Ekşi MŞ, Uçar T. Health-related quality of life measures in patients undergoing decompressive craniectomy for severe traumatic brain injury: a 6-year follow-up analysis. Int J Neurosci 2024:1-9. [PMID: 38446112 DOI: 10.1080/00207454.2024.2327400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 03/02/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE We aimed to assess the long-term neurological outcomes and the functionality and QoL in patients undergoing decompressive craniectomy for severe traumatic brain injury, respectively. MATERIALS AND METHODS Among the 120 patients who underwent decompressive craniectomy for severe TBI between 2002 and 2007, 101 were included based on the inclusion criteria. Long-term follow-up results (minimum 3 years) were available for 22 patients. The outcomes were assessed using the Glasgow Outcome Scale (GOS) and the functionality and HRQoL were assessed using the Short Form-36 (SF-36) (v2) and Quality of Life After Brain Injury (QoLIBRI) questionnaires. RESULTS Among the patients with severe TBI, 62 (61.4%) died and 39 (38.6%) were discharged to either home or a physical therapy facility. Eleven of the thirty-nine patients could not be reached and were excluded from the final analysis. The mean GOS of the remaining 28 patients was 4.14 ± 0.8 after 6.46 ± 1.64 years of follow-up. The HRQoL was assessed in 22 of the 28 patients. The HRQoL scores were lower in patients with TBI than in healthy controls. Furthermore, there was a significant difference in the HRQoL scores in patients with improved GOS scores than in those with unimproved GOS scores. CONCLUSIONS Health-related outcome scores could help clinicians understand the requirements of survivors of severe TBI to create a realistic rehabilitation target for them. QoLIBRI served as a good way of communication in these subjects.
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Affiliation(s)
- Umut Ogün Mutlucan
- Department of Neurosurgery, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ömer Orhun
- School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Emel Ece Özcan-Ekşi
- Physical Medicine and Rehabilitation Unit, Acıbadem Bağdat Caddesi Medical Center, Istanbul, Turkey
| | - Murat Şakir Ekşi
- Department of Neurosurgery, School of Medicine, Health Sciences University, Istanbul, Turkey
- FSM Training and Research Hospital, Neurosurgery Clinic, Istanbul, Turkey
| | - Tanju Uçar
- Department of Neurosurgery, Akdeniz University, School of Medicine, Antalya, Turkey
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4
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Abdulla E, Das K, Sridharan K, Waheed M, Abdulla F, Ravindra J, Luther H, Wireko AA. Prognostic variables predict clinical outcome after decompressive craniectomy: A single institute experience; A retrospective study. Medicine (Baltimore) 2024; 103:e36876. [PMID: 38181236 PMCID: PMC10766213 DOI: 10.1097/md.0000000000036876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/15/2023] [Indexed: 01/07/2024] Open
Abstract
Decompressive craniectomy (DC) is a well-established neurosurgical intervention in patients with high intracranial pressure who fail to respond to medical treatment. Data on predictive factors for functional outcomes in patients with DC who have malignant middle cerebral artery (MCA) infarction as opposed to intracranial hemorrhage (ICH) are scarce. Eighty-four patients who underwent DC treatment for ICH and malignant MCA infarction were examined. All patients underwent surgery in the Bahrain Salmaniya Medical Complex Neurosurgery Unit between January 2017 and June 2021. To determine whether any of these demonstrated a link to the functional outcome, radiographic factors were compared with clinical data. The postsurgical midline shift (MLS) (ICH group) showed the strongest correlation (ρ = 0.434; P = .006), as in the MCA infarction group as well (ρ = 0.46; P = .005). Further analyses using binary logistic regression with postsurgical basal cistern status and ∆ MLS, and it was observed to be statistically significant (odds ratios: 0.067, 95% CI: 0.007, 0.67; P = .021). The initial Glasgow coma scale, postsurgical MLS, basal cistern status, and ∆ are Measurable variables that can be used to predict outcomes in the groups with ICH and MCA infarction.
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Affiliation(s)
- Ebtesam Abdulla
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Krishna Das
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Kannan Sridharan
- Department of Pharmacology and Therapeutics, Arabian Gulf University, Manama, Bahrain
| | - Mohammed Waheed
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Fatima Abdulla
- Department of Neurology, Salmaniya Medical Complex, Manama, Bahrain
| | - Joseph Ravindra
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Harleen Luther
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
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Omerhodzic I, Dzurlic A, Rovcanin B, Rotim K, Hadzimehmedagic A, Ahmetspahic A, Zvizdic Z, Granov N, Suljic E. Hinge craniotomy as an alternative technique for patients with refractory intracranial hypertension. BRAIN & SPINE 2023; 3:101758. [PMID: 37383443 PMCID: PMC10293230 DOI: 10.1016/j.bas.2023.101758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 06/30/2023]
Abstract
Introduction Decompressive craniectomy (DC) can save brain tissue, but unfortunately it has many limitations and complications. Hinge craniotomy (HC), as less aggressive method seems to be adequate alternative not only to DC but also to conservative treatment. Research question Presentation of the results of modified surgical techniques of cranial decompression and comparing with more and less aggressive medical options. Material and methods A prospective clinical study was conducted during 86 months. Comatose patients who suffered refractory intracranial hypertension (RIH) were treated. Altogether, 137 patients have been evaluated. The final outcome of all patients in the study was evaluated after 6 months. Results Both surgical options resulted in adequate control of intracranial pressure (ICP). HC method was shown to have the lowest probability of worsening from a prior state of relative stability. Discussion and conclusion There was no statistically significant difference between methods to treatment of DC or HC, meaning the final outcome of patients treated in any manner. There was similar rate of early and late complications.
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Affiliation(s)
- Ibrahim Omerhodzic
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Almir Dzurlic
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Bekir Rovcanin
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Kresimir Rotim
- Department of Neurosurgery, Clinical Hospital Center Sisters of Mercy, Zagreb, Croatia
| | - Amel Hadzimehmedagic
- Department of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Adi Ahmetspahic
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Zlatan Zvizdic
- Department of Pediatric Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Nermir Granov
- Department of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Enra Suljic
- Department of Neurology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Yang C, Hui J, Xie L, Feng J, Jiang J. Comparative effectiveness of different surgical procedures for traumatic acute epidural haematoma: study protocol for Prospective, Observational Real-world Treatments of AEDH in Large-scale Surgical Cases (PORTALS-AEDH). BMJ Open 2022; 12:e051247. [PMID: 35264341 PMCID: PMC8915281 DOI: 10.1136/bmjopen-2021-051247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Controversy and variation exist in surgical management for acute epidural haematoma (AEDH). Although craniotomy for AEDH is conventionally employed, no specific evaluation on the necessity of decompressive craniectomy (DC) followed by AEDH evacuation has been performed. METHODS AND ANALYSIS This is a multicentre prospective, phase III observational study that evaluates different surgical managements for the AEDH. Patients of both genders, aged 18-65 years, presenting to the emergency room with a clinical and radiological diagnosis of AEDH, complying with other inclusion and exclusion criteria, are enrolled. Clinical information, including diagnosis of AEDH, radiological information, treatment procedures and follow-up data of 1, 3 and 6 months post-injury, is collected on 2000 eligible patients among 263 hospitals in China. Recruitment for the study started in April 2021, and inclusion will be continued until the sample size is obtained, expected is an inclusion period of 24 months. The interventions of concern are surgical treatments for AEDH, including craniotomy and DC. The primary outcome is the Glasgow Outcome Score-Extended 6 months post-injury. Secondary outcomes include the incidence of postoperative cerebral infarction, the incidence of additional craniocerebral surgery and other evaluation indicators within 6 months post-injury. ETHICS AND DISSEMINATION The study protocol has been approved by the ethics committee and institutional review board of Renji Hospital, School of Medicine, Shanghai Jiao Tong University. All study investigators strictly follow the Declaration of Helsinki and Human Biomedical Research Ethical Issues. Signed written informed consent will be obtained from all enrolled patients. The trial results will be disseminated through academic conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04229966.
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Affiliation(s)
- Chun Yang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Jiyuan Hui
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junfeng Feng
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Jiyao Jiang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
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7
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Development of large contralateral MCA infarct following cranioplasty for decompressive craniectomy for ipsilateral large MCA infarct – A rare case report. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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8
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Raman V, Jiwrajka M, Pollard C, Grieve DA, Alexander H, Redmond M. Emergent craniotomy in rural and regional settings - recommendations from a tertiary neurosurgery unit: surgical technique and future prospects. ANZ J Surg 2022; 92:980-987. [PMID: 35037369 DOI: 10.1111/ans.17457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/12/2021] [Accepted: 12/21/2021] [Indexed: 11/28/2022]
Abstract
Kenneth G Jamieson described the emergent craniotomy for traumatic brain injuries (TBI) in the rural and regional setting back in 1965 in his book 'A First Notebook Of Head Injury'. Since then, there has been successful use of the technique in peripheral hospitals prior to the safe transfer of patients to metropolitan trauma centres. Although the procedure can be daunting in inexperienced hands, our institution supports ongoing education to continue implementation of trauma craniotomies by non-neurosurgeons if it means another life is potentially saved. Here we describe the surgical technique for an emergent craniotomy and craniectomy. Although the surgical technique has been described elsewhere, we have done so in a simplified 10-step approach with consideration of available resources in the peripheral hospital setting and the added pearls from the experience of a metropolitan neurosurgical unit. We also discuss future prospects for undertaking neurosurgical operations in peripheral hospitals but with intra-operative tele-surgery monitoring and supervision.
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Affiliation(s)
- Vignesh Raman
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Manasi Jiwrajka
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, University of Queensland, Brisbane, Queensland, Australia
| | - Cliff Pollard
- Jamieson Trauma Institute, Brisbane, Queensland, Australia
| | - David A Grieve
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia.,School of Medicine, Griffith University, Sunshine Coast, Queensland, Australia
| | - Hamish Alexander
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, University of Queensland, Brisbane, Queensland, Australia
| | - Michael Redmond
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, University of Queensland, Brisbane, Queensland, Australia.,Department of Neurosurgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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9
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Augmentation of Supratemporal Hollowing With Silicone Block During Autologous Cranioplasty After Decompressive Craniectomy With Additional Temporalis Resection. J Craniofac Surg 2021; 32:e645-e647. [PMID: 33852524 DOI: 10.1097/scs.0000000000007651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Decompressive craniectomy is a potentially life-saving neurosurgical procedure. In cases of insufficient decompression, uncontrolled intracranial pressure even after sufficient decompression, or when the intracranial pressure is increased due to external factors such as intramuscular hematoma in the temporal muscle, additional temporalis resection may be necessary. However, the hollowing of the supratemporal fossa that occurs after additional temporalis resection can create a major cosmetic problem. Several alternatives are available to fill the hollowing of the supratemporal fossa during cranial reconstruction, but each has a disadvantage, whether it is expensive or difficult to shape for bilateral symmetry. The author solved the cosmetic problem by using a properly carved silicone block to fill the supratemporal fossa while conducting cranioplasty, and here reports it with a literature review.
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10
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Yang C, Huang X, Feng J, Xie L, Hui J, Li W, Jiang J. Prospective Randomized Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Hematoma (PREDICT-AEDH): study protocol for a randomized controlled trial. Trials 2021; 22:421. [PMID: 34187537 PMCID: PMC8244162 DOI: 10.1186/s13063-021-05359-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/07/2021] [Indexed: 11/27/2022] Open
Abstract
Background The expeditious surgical evacuation of acute epidural hematoma (AEDH) is an attainable gold standard and is often expected to have a good clinical outcome for patients with surgical indications. However, controversy exists on the optimal surgical options for AEDH, especially for patients with brain herniation. Neurosurgeons are confronted with the decision to evacuate the hematoma with decompressive craniectomy (DC) or craniotomy. Methods/design Patients of both sexes, age between 18 and 65 years, who presented to the emergency room with a clinical and radiological diagnosis of AEDH with herniation, were assessed against the inclusion and exclusion criteria to be enrolled in the study. Clinical and radiological information, including diagnosis of AEDH, treatment procedures, and follow-up data at 1, 3, and 6 months after injury, was collected from 120 eligible patients in 51 centers. The patients were randomized into groups of DC versus craniotomy in a 1:1 ratio. The primary outcome was the Glasgow Outcome Score-Extended (GOSE) at 6 months post-injury. Secondary outcomes included incidence of postoperative cerebral infarction, incidence of additional craniocerebral surgery, and other evaluation indicators within 6 months post-injury. Discussion This study is expected to support neurosurgeons in their decision to evacuate the epidural hematoma with or without a DC, especially in patients with brain herniation, and provide additional evidence to improve the knowledge in clinical practice. Trial registration ClinicalTrials.govNCT 04261673. Registered on 04 February 2020
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Affiliation(s)
- Chun Yang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China.,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Xianjian Huang
- Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Shenzhen, Guangdong, People's Republic of China
| | - Junfeng Feng
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China.,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, 227 Chongqing South Road, Shanghai, People's Republic of China
| | - Jiyuan Hui
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China.,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China
| | - Weiping Li
- Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Shenzhen, Guangdong, People's Republic of China.
| | - Jiyao Jiang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, People's Republic of China. .,Shanghai Institute of Head Trauma, Shanghai, People's Republic of China.
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11
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Ozoner B, Kilic M, Aydin L, Aydin S, Arslan YK, Musluman AM, Yilmaz A. Early cranioplasty associated with a lower rate of post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury. Eur J Trauma Emerg Surg 2020; 46:919-926. [PMID: 32494837 DOI: 10.1007/s00068-020-01409-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/22/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Post-traumatic hydrocephalus (PTH) is one of the primary complications during the course of traumatic brain injury (TBI). The aim of this study was to define factors associated with the development of PTH in patients who underwent unilateral decompressive craniectomy (DC) for TBI. METHODS A total of 126 patients, who met the inclusion criteria of the study, were divided into two groups: patients with PTH (n = 25) and patients without PTH (n = 101). Their demographic, clinical, radiological, operative, and postoperative factors, which may be associated with the development of PTH, were compared. RESULTS Multivariate logistic regression analysis revealed that cranioplasty performed later than 2 months following DC was significantly associated with the requirement for ventriculoperitoneal shunting due to PTH (p < 0.001). Also, a significant unfavorable outcome rate was observed in patients with PTH at 1-year follow-up according to the Glasgow Outcome Scale-Extended (p = 0.047). CONCLUSIONS Our results show that early cranioplasty within 2 months after DC was associated with a lower rate of PTH development after TBI.
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Affiliation(s)
- Baris Ozoner
- Department of Neurosurgery, School of Medicine, Bahcesehir University, Istanbul, Turkey. .,School of Medicine, Department of Neurosurgery, Erzincan Binali Yildirim University, Erzincan, Turkey.
| | - Mustafa Kilic
- Department of Neurosurgery, Sisli Hamidiye Etfal Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Levent Aydin
- Department of Neurosurgery, Sisli Hamidiye Etfal Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Seckin Aydin
- Department of Neurosurgery, Okmeydani Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Yusuf Kemal Arslan
- Department of Biostatistics, School of Medicine, Erzincan Binali Yildirim University, Erzincan, Turkey
| | - Ahmet Murat Musluman
- Department of Neurosurgery, Sisli Hamidiye Etfal Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Adem Yilmaz
- Department of Neurosurgery, Sisli Hamidiye Etfal Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
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12
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Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
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Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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Whitney E, Mahato D, Odell T, Khan YR, Siddiqi J. The 100-most Cited Articles About Craniectomy and Hemicraniectomy: A Bibliometric Analysis. Cureus 2019; 11:e5524. [PMID: 31687299 PMCID: PMC6819074 DOI: 10.7759/cureus.5524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Craniectomy is a life-saving procedure used in the setting of traumatic brain injury, stroke and increased intracranial pressure. The purpose of this study was to analyze and determine the most influential articles and authors in the field of craniectomy. Our study presents an analysis of the articles that include the word "craniectomy" or "hemicraniectomy" in the title and a detailed analysis of the top 100-cited articles in that selection. This search provided insight into how this procedure was initially documented and how it has been utilized over the years. We used the SCOPUS database to search “craniectomy OR hemicraniectomy” in the article title. We then sorted the top 100 most-cited articles. Bibliometric analysis was performed. An H-index was presented with each author. The citation count ranged from 71 to 5310. The most published author was Werner Hacke, a German researcher (n=6). The highest quantity of influential work was published in 2006 and 2007 (n=9/yr). The United States published the most articles (n=42). The Journal of Neurosurgery published 21 of the top 100 most-cited articles. The chronological timeline shows the evolution of decompression as it related to both stroke and trauma. It demonstrated that well-cited articles acted as turning points to direct further scientific endeavors while highlighting the hard work of certain authors. There is, to the best of our knowledge, a shortage of literature on a bibliometric analysis regarding the term craniectomy. Thus, the current bibliometric study was undertaken to highlight the work of authors who have advanced knowledge about this procedure. It provides an analysis of the top 100-cited articles with craniectomy in the title with dates ranging from 1892 to 2016. A review of its publication history shows how interventions in this field have advanced over the last several decades.
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Affiliation(s)
- Eric Whitney
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | | | - Tiffany Odell
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Yasir R Khan
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Javed Siddiqi
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
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14
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Abstract
Raised intracranial pressure (rICP) syndrome is seen in various pathologies. Appropriate and systematic management is important for favourable patient outcome. This review describes the stepwise approach to control the raised ICP in a tiered manner, with increasing aggressiveness. The role of ICP measurement in the assessment of cerebral autoregulation and individualised management is discussed. Although a large amount of research has been undertaken for the management of raised ICP, there still remain unanswered questions. This review tries to put together the best evidence in a succinct manner. HOW TO CITE THIS ARTICLE Tripathy S, Ahmad SR. Raised Intracranial Pressure Syndrome: A Stepwise Approach. Indian J Crit Care Med 2019;23(Suppl 2):S129-S135.
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Affiliation(s)
- Swagata Tripathy
- Department of Anesthesia and Intensive Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Suma Rabab Ahmad
- Department of Anesthesia and Intensive Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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15
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Shim HK, Yu SH, Kim BC, Lee JH, Choi HJ. Relationship between Clinical Outcomes and Superior Sagittal Sinus to Bone Flap Distance during Unilateral Decompressive Craniectomy in Patients with Traumatic Brain Injury: Experience at a Single Trauma Center. Korean J Neurotrauma 2018; 14:99-104. [PMID: 30402426 PMCID: PMC6218355 DOI: 10.13004/kjnt.2018.14.2.99] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/03/2018] [Accepted: 08/10/2018] [Indexed: 01/21/2023] Open
Abstract
Objective This retrospective study was conducted to investigate the relationship between the superior sagittal sinus (SSS) to bone flap distance and clinical outcome in patients with traumatic brain injury (TBI) who underwent decompressive craniectomy (DC). Methods A retrospective review of medical records identified 255 adult patients who underwent DC with hematoma removal to treat TBI at our hospital from 2016 through 2017; of these, 68 patients met the inclusion criteria and underwent unilateral DC. The nearest SSS to bone flap distances were measured on postoperative brain computed tomography images, and patients were divided into groups A (distance ≥20 mm) and B (distance <20 mm). The estimated blood loss (EBL) and operation time were evaluated using anesthesia records, and the time spent in an intensive care unit (ICU) was obtained by chart review. The clinical outcome was rated using the extended Glasgow Outcome Scale (GOS-E) at 3 and 6 months postoperatively. Results The male to female ratio was 15:2 and the mean subject age was 55.12 years (range, 18–79 years). The mean EBL and operation times were significantly different between groups A and B (EBL: 655.26 vs. 1803.33 mL, p<0.001; operation time: 125.92 vs. 144.83 min, p<0.001). The time spent in the ICU and GOS-E scores did not differ significantly between the groups. Conclusion We recommend that when DC is indicated due to TBI, an SSS to bone flap distance of at least 20 mm should be maintained, considering the EBL, operation time, and other outcomes.
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Affiliation(s)
- Hyuk Ki Shim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Seung Han Yu
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung Chul Kim
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Jung Hwan Lee
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hyuk Jin Choi
- Department of Neurosurgery and Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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16
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van Essen TA, Dijkman MD, Cnossen MC, Moudrous W, Ardon H, Schoonman GG, Steyerberg EW, Peul WC, Lingsma HF, de Ruiter GCW. Comparative Effectiveness of Surgery for Traumatic Acute Subdural Hematoma in an Aging Population. J Neurotrauma 2018; 36:1184-1191. [PMID: 30234429 DOI: 10.1089/neu.2018.5869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
There is uncertainty as to the optimal initial management of patients with traumatic acute subdural hematoma, leading to regional variation in surgical policy. This can be exploited to compare the effect of various management strategies and determine best practices. This article reports such a comparative effectiveness analysis of a retrospective observational cohort of traumatic acute subdural hematoma patients in two geographically distinct neurosurgical departments chosen for their - a-priori defined - diverging treatment preferences. Region A favored a strategy focused on surgical hematoma evacuation, whereas region B employed a more conservative approach, performing primary surgery less often. Region was used as a proxy for preferred treatment strategy to compare outcomes between groups, adjusted for potential confounders using multivariable logistic regression with imputation of missing data. In total, 190 patients were included: 108 from region A and 82 from region B. There were 104 males (54.7%). Matching current epidemiological developments, the median age was relatively high at 68 years (interquartile range [IQR], 54-76). Baseline characteristics were comparable between regions. Primary evacuation was performed in 84% of patients in region A and in 65% of patients in region B (p < 0.01). Mortality was lower in region A (37% vs. 45%, p = 0.29), as was unfavorable outcome (53% vs. 62%, p = 0.23). The strategy favoring surgical evacuation was associated with significantly lower odds of mortality (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.21-0.88) and unfavorable outcome (OR: 0.53; 95% CI: 0.27-1.02) 3-9 months post-injury. Therefore, in the aging population of patients with acute subdural hematoma, a treatment strategy favoring emergency hematoma evacuation might be associated with lower odds of mortality and unfavorable outcome.
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Affiliation(s)
- Thomas A van Essen
- 1 Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.,2 Department of Neurosurgery, Medial Center Haaglanden, The Hague, The Netherlands
| | - Mark D Dijkman
- 1 Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Maryse C Cnossen
- 3 Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Walid Moudrous
- 4 Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,5 Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Hilko Ardon
- 6 Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Guus G Schoonman
- 4 Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Ewout W Steyerberg
- 3 Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.,7 Department of Medical Statistics and Bioinformatics,, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilco C Peul
- 1 Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.,2 Department of Neurosurgery, Medial Center Haaglanden, The Hague, The Netherlands
| | - Hester F Lingsma
- 3 Center for Medical Decision Sciences, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Godard C W de Ruiter
- 2 Department of Neurosurgery, Medial Center Haaglanden, The Hague, The Netherlands
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17
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Waqas M, Malik N, Shamim MS, Nathani KR, Abbasi SA. Quality of Life Among Patients Undergoing Decompressive Craniectomy for Traumatic Brain Injury Using Glasgow Outcome Scale Extended and Quality of Life After Brain Injury Scale. World Neurosurg 2018; 116:e783-e790. [DOI: 10.1016/j.wneu.2018.05.092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/13/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
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18
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Badke GL, Araujo JLV, Miura FK, Guirado VMDP, Saade N, Paiva ALC, Avelar TM, Pedrozo CAG, Veiga JCE. Analysis of direct costs of decompressive craniectomy in victims of traumatic brain injury. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:257-264. [DOI: 10.1590/0004-282x20180016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 12/19/2017] [Indexed: 11/22/2022]
Abstract
ABSTRACT Background: Decompressive craniectomy is a procedure required in some cases of traumatic brain injury (TBI). This manuscript evaluates the direct costs and outcomes of decompressive craniectomy for TBI in a developing country and describes the epidemiological profile. Methods: A retrospective study was performed using a five-year neurosurgical database, taking a sample of patients with TBI who underwent decompressive craniectomy. Several variables were considered and a formula was developed for calculating the total cost. Results: Most patients had multiple brain lesions and the majority (69.0%) developed an infectious complication. The general mortality index was 68.8%. The total cost was R$ 2,116,960.22 (US$ 661,550.06) and the mean patient cost was R$ 66,155.00 (US$ 20,673.44). Conclusions: Decompressive craniectomy for TBI is an expensive procedure that is also associated with high morbidity and mortality. This was the first study performed in a developing country that aimed to evaluate the direct costs. Prevention measures should be a priority.
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Affiliation(s)
| | - João Luiz Vitorino Araujo
- Santa Casa de São Paulo, Brasil; Hospital Israelista Albert Einstein, Brasil; Instituto do Câncer Arnaldo Vieira de Carvalho, Brasil
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19
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Weickenmeier J, Saze P, Butler CAM, Young PG, Goriely A, Kuhl E. Bulging brains. JOURNAL OF ELASTICITY 2017; 129:197-212. [PMID: 29151668 PMCID: PMC5687257 DOI: 10.1007/s10659-016-9606-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Indexed: 06/07/2023]
Abstract
Brain swelling is a serious condition associated with an accumulation of fluid inside the brain that can be caused by trauma, stroke, infection, or tumors. It increases the pressure inside the skull and reduces blood and oxygen supply. To relieve the intracranial pressure, neurosurgeons remove part of the skull and allow the swollen brain to bulge outward, a procedure known as decompressive craniectomy. Decompressive craniectomy has been preformed for more than a century; yet, its effects on the swollen brain remain poorly understood. Here we characterize the deformation, strain, and stretch in bulging brains using the nonlinear field theories of mechanics. Our study shows that even small swelling volumes of 28 to 56 ml induce maximum principal strains in excess of 30%. For radially outward-pointing axons, we observe maximal normal stretches of 1.3 deep inside the bulge and maximal tangential stretches of 1.3 around the craniectomy edge. While the stretch magnitude varies with opening site and swelling region, our study suggests that the locations of maximum stretch are universally shared amongst all bulging brains. Our model has the potential to inform neurosurgeons and rationalize the shape and position of the skull opening, with the ultimate goal to reduce brain damage and improve the structural and functional outcomes of decompressive craniectomy in trauma patients.
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Affiliation(s)
- J Weickenmeier
- Department of Mechanical Engineering, Stanford University, Stanford, CA 94305, USA,
| | - P Saze
- Laboratori de Calcul Numeric, Universitat Universitat Politècnica de Catalunya Barcelona-Tech, 08034 Barcelona, Spain,
| | - C A M Butler
- Synopsys/Simpleware, Bradninch Hall, Castle Street, Exeter EX4 3PL, UK
| | - P G Young
- College of Engineering, University of Exeter, Exeter, Devon, UK
| | - A Goriely
- Mathematical Institute, University of Oxford, Oxford, OX2 6GG, UK,
| | - E Kuhl
- Department of Mechanical Engineering and Department of Bioengineering, Stanford University, Stanford, CA 94305, USA,
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20
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Yue JK, Rick JW, Deng H, Feldman MJ, Winkler EA. Efficacy of decompressive craniectomy in the management of intracranial pressure in severe traumatic brain injury. J Neurosurg Sci 2017; 63:425-440. [PMID: 29115100 DOI: 10.23736/s0390-5616.17.04133-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Traumatic brain injury (TBI) is a common cause of permanent disability for which clinical management remains suboptimal. Elevated intracranial pressure (ICP) is a common sequela following TBI leading to death and permanent disability if not properly managed. While clinicians often employ stepwise acute care algorithms to reduce ICP, a number of patients will fail medical management and may be considered for surgical decompression. Decompressive craniectomy (DC) involves removing a component of the bony skull to allow cerebral tissue expansion in order to reduce ICP. However, the impact of DC, which is performed in the setting of neurological instability, ongoing secondary injury, and patient resuscitation, has been challenging to study and outcomes are not well understood. This review summarizes historical and recent studies to elucidate indications for DC and the nuances, risks and complications in its application. The pathophysiology driving ICP elevation, and the corresponding medical interventions for their temporization and treatment, are thoroughly described. The current state of DC - including appropriate injury classification, surgical techniques, concurrent medical therapies, mortality and functional outcomes - is presented. We also report on the recent updates from large randomized controlled trials in severe TBI (Decompressive Craniectomy [DECRA] and Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP [RESCUEicp]), and recommendations for early DC to treat refractory ICP elevations in malignant middle cerebral artery syndrome. Limitations for DC, such as the equipoise between immediate reduction in ICP and clinically meaningful functional outcomes, are discussed in support of future investigations.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Jonathan W Rick
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael J Feldman
- Department of Neurological Surgery, Vanderbilt University, Nashville, TN, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, CA, USA -
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21
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Kramer AH, Deis N, Ruddell S, Couillard P, Zygun DA, Doig CJ, Gallagher C. Decompressive Craniectomy in Patients with Traumatic Brain Injury: Are the Usual Indications Congruent with Those Evaluated in Clinical Trials? Neurocrit Care 2017; 25:10-9. [PMID: 26732269 DOI: 10.1007/s12028-015-0232-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND In patients with traumatic brain injury (TBI), multicenter randomized controlled trials have assessed decompressive craniectomy (DC) exclusively as treatment for refractory elevation of intracranial pressure (ICP). DC reliably lowers ICP but does not necessarily improve outcomes. However, some patients undergo DC as treatment for impending or established transtentorial herniation, irrespective of ICP. METHODS We performed a population-based cohort study assessing consecutive patients with moderate-severe TBI. Indications for DC were compared with enrollment criteria for the DECRA and RESCUE-ICP trials. RESULTS Of 644 consecutive patients, 51 (8 %) were treated with DC. All patients undergoing DC had compressed basal cisterns, 82 % had at least temporary preoperative loss of ≥1 pupillary light reflex (PLR), and 80 % had >5 mm of midline shift. Most DC procedures (67 %) were "primary," having been performed concomitantly with evacuation of a space-occupying lesion. ICP measurements influenced the decision to perform DC in 18 % of patients. Only 10 and 16 % of patients, respectively, would have been eligible for the DECRA and RESCUE-ICP trials. DC improved basal cistern compression in 76 %, and midline shift in 94 % of patients. Among patients with ≥1 absent PLR at admission, DC was associated with lower mortality (46 vs. 68 %, p = 0.03), especially when the admission Marshall CT score was 3-4 (p = 0.0005). No patients treated with DC progressed to brain death. Variables predictive of poor outcome following DC included loss of PLR(s), poor motor score, midline shift ≥11 mm, and development of perioperative cerebral infarcts. CONCLUSIONS DC is most often performed for clinical and radiographic evidence of herniation, rather than for refractory ICP elevation. Results of previously completed randomized trials do not directly apply to a large proportion of patients undergoing DC in practice.
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Affiliation(s)
- Andreas H Kramer
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada. .,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada. .,Hotchkiss Brain Institute, Calgary, AB, Canada.
| | - Nathan Deis
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Stacy Ruddell
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada
| | - Philippe Couillard
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, Calgary, AB, Canada
| | - David A Zygun
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Christopher J Doig
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Clare Gallagher
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W., Calgary, AB, T2N 2T9, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, Calgary, AB, Canada
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23
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Jonsdottir GM, Lund SH, Snorradottir B, Karason S, Olafsson IH, Reynisson K, Mogensen B, Sigvaldason K. A population-based study on epidemiology of intensive care unit treated traumatic brain injury in Iceland. Acta Anaesthesiol Scand 2017; 61:408-417. [PMID: 28194757 DOI: 10.1111/aas.12869] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Traumatic brain injury is a worldwide health issue and a significant cause of preventable deaths and disabilities. We aimed to describe population-based data on intensive care treated traumatic brain injury in Iceland over 15 years period. METHODS Retrospective review of all intensive care unit admissions due to traumatic brain injury at The National University Hospital of Iceland 1999-2013. Data were collected on demographics, mechanism of injury, alcohol consumption, glasgow come scale upon admission, Injury Severity Scoring, acute physiology and chronic health evaluation II score, length of stay, interventions and mortality (defined as glasgow outcome score one). All computerized tomography scans were reviewed for Marshall score classification. RESULTS Intensive care unit admissions due to traumatic brain injury were 583. The incidence decreased significantly from 14/100.000/year to 12/100.000/year. Males were 72% and the mean age was 41 year. Majority of patients (42%) had severe traumatic brain injury. The most common mechanism of injury was a fall from low heights (36.3%). The mortality was 18.2%. Increasing age, injury severity score, Marshall score and acute physiology and chronic health evaluation II score are all independent risk factors for death. Glasgow coma scale was not an independent prognostic factor for outcome. CONCLUSIONS Incidence decreased with a shift in injury mechanism from road traffic accidents to falls and an increased rate of traumatic brain injury in older patients following a fall from standing or low heights. Mortality was higher in older patients falling from low heights than in younger patients suffering multiple injuries in road traffic accidents. Age, injury severity score, acute physiology and chronic health evaluation II score and Marshall score are good prognostic factors for outcome. Traumatic brain injury continues to be a considerable problem and the increase in severe traumatic brain injury in the middle age and older age groups after a seemingly innocent accident needs a special attention.
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Affiliation(s)
- G. M. Jonsdottir
- Department of Anesthesia and Intensive Care Medicine; The National University Hospital of Iceland; Reykjavik Iceland
| | - S. H. Lund
- Center of Public Health Sciences; University of Iceland; Reykjavik Iceland
| | - B. Snorradottir
- Department of Anesthesia and Intensive Care Medicine; The National University Hospital of Iceland; Reykjavik Iceland
| | - S. Karason
- Department of Anesthesia and Intensive Care Medicine; The National University Hospital of Iceland; Reykjavik Iceland
- Faculty of Medicine; University of Iceland; Reykjavik Iceland
| | - I. H. Olafsson
- Faculty of Medicine; University of Iceland; Reykjavik Iceland
- Department of Neurosurgery; The National University Hospital of Iceland; Reykjavik Iceland
| | - K. Reynisson
- Department of Radiology; The National University Hospital of Iceland; Reykjavik Iceland
| | - B. Mogensen
- Faculty of Medicine; University of Iceland; Reykjavik Iceland
- Department of Emergency; The National University Hospital of Iceland; Reykjavik Iceland
| | - K. Sigvaldason
- Department of Anesthesia and Intensive Care Medicine; The National University Hospital of Iceland; Reykjavik Iceland
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24
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Abstract
There have been many recent advances in the management of traumatic brain injury (TBI). Research regarding established and novel therapies is ongoing. Future research must not only focus on development of new strategies but determine the long-term benefits or disadvantages of current strategies. In addition, the impact of these advances on varying severities of brain injury must not be ignored. It is hoped that future research strategies in TBI will prioritize large-scale trials using common data elements to develop large registries and databases, and leverage international collaborations.
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Affiliation(s)
- Deborah M Stein
- Neurotrauma Critical Care, Section of Trauma Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Cristina B Feather
- Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Lena M Napolitano
- Division of Acute Care Surgery [Trauma, Burns, Surgical Critical Care, Emergency Surgery], Department of Surgery, Trauma and Surgical Critical Care, University of Michigan Health System, Room 1C340-UH, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5033, USA
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Abstract
Traumatic brain injury (TBI) continues to be a major public health problem. Proposed treatments have not withstood testing in clinical trials because of failure to account for different types of TBI and other weaknesses in trial design. Management goals continue to be prevention and prompt treatment of secondary insults (hypotension, hypoxia, and other physiologic derangements). This goal is best accomplished by careful attention to airway, breathing, circulation, and basic principles of intensive care unit management. Attempts to intervene prophylactically to prevent intracranial hypertension or other complications have not been beneficial and may even have deleterious effects.
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Affiliation(s)
- Wittstatt Alexandra Whitaker-Lea
- Department of Neurosurgery, Virginia Commonwealth University, 417 North 11th Street, 6th Floor, PO Box 980631, Richmond, VA 23298-0631, USA
| | - Alex B Valadka
- Department of Neurosurgery, Virginia Commonwealth University, 417 North 11th Street, 6th Floor, PO Box 980631, Richmond, VA 23298-0631, USA.
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Athanasiou A, Balogiannis I, Magras I. Lasting bilateral mydriasis after traumatic brain injury may not always be a lost case. Surg Neurol Int 2017; 8:229. [PMID: 29026665 PMCID: PMC5629836 DOI: 10.4103/sni.sni_299_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 11/17/2022] Open
Abstract
Background: Lasting bilateral mydriasis and absence of pupillary light reflex following severe traumatic brain injury (TBI) are considered signs of irreversible brainstem damage and have been strongly associated with poor outcome. Case Description: A young female patient presented with severe TBI, contusions, and diffuse brain edema. She was initially treated medically, but developed delayed secondary refractory intracranial hypertension and bilaterally dilated, non-reactive pupils for 12 h. Wide decompressive craniectomy and dural incisions were performed. The patient presented gradual improvement in her clinical condition [Glasgow Coma Scale (GCS) 13/15]. Delayed recurring infections lead to the patient's death due to sepsis after 3 months. Conclusion: In light of recent studies, lasting bilateral mydriasis may not always be considered a decisive factor for non-escalation of treatment, as variability among TBI patients and outcomes has been demonstrated. Wide decompressive craniectomy is viable for controlling refractory intracranial hypertension in hemodynamically stable patients.
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Miller K, Eljamel S. Does Size and Site Matter in Therapeutic Decompressive Craniectomy? A Laboratory-Based Experimental Study. World Neurosurg 2016; 95:441-446. [DOI: 10.1016/j.wneu.2016.08.061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/12/2016] [Accepted: 08/13/2016] [Indexed: 11/30/2022]
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Adams H, Kolias AG, Hutchinson PJ. The Role of Surgical Intervention in Traumatic Brain Injury. Neurosurg Clin N Am 2016; 27:519-28. [DOI: 10.1016/j.nec.2016.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Traumatic brain injuries (TBIs) in children are a major cause of morbidity and mortality worldwide. Severe TBIs account for 15,000 admissions annually and a mortality rate of 24% in children in the United States. The purpose of this article is to explore pathophysiologic events, examine monitoring techniques, and explain current treatment modalities and nursing care related to caring for children with severe TBI. The primary injury of a TBI is because of direct trauma from an external force, a penetrating object, blast waves, or a jolt to the head. Secondary injury occurs because of alterations in cerebral blood flow, and the development of cerebral edema leads to necrotic and apoptotic cellular death after TBI. Monitoring focuses on intracranial pressure, cerebral oxygenation, cerebral edema, and cerebrovascular injuries. If abnormalities are identified, treatments are available to manage the negative effects caused to the cerebral tissue. The mainstay treatments are hyperosmolar therapy; temperature control; cerebrospinal fluid drainage; barbiturate therapy; decompressive craniectomy; analgesia, sedation, and neuromuscular blockade; and antiseizure prophylaxis.
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Gopaul R, Wei ZD, Yan J, Gong FY, Xiao SW. Clinical study of quality of life of traumatic brain injury patients after decompressive craniectomy and related influencing factors. Chin Neurosurg J 2016. [DOI: 10.1186/s41016-016-0044-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med 2016; 375:1119-30. [PMID: 27602507 DOI: 10.1056/nejmoa1605215] [Citation(s) in RCA: 680] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The effect of decompressive craniectomy on clinical outcomes in patients with refractory traumatic intracranial hypertension remains unclear. METHODS From 2004 through 2014, we randomly assigned 408 patients, 10 to 65 years of age, with traumatic brain injury and refractory elevated intracranial pressure (>25 mm Hg) to undergo decompressive craniectomy or receive ongoing medical care. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOS-E) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 6 months. The primary-outcome measure was analyzed with an ordinal method based on the proportional-odds model. If the model was rejected, that would indicate a significant difference in the GOS-E distribution, and results would be reported descriptively. RESULTS The GOS-E distribution differed between the two groups (P<0.001). The proportional-odds assumption was rejected, and therefore results are reported descriptively. At 6 months, the GOS-E distributions were as follows: death, 26.9% among 201 patients in the surgical group versus 48.9% among 188 patients in the medical group; vegetative state, 8.5% versus 2.1%; lower severe disability (dependent on others for care), 21.9% versus 14.4%; upper severe disability (independent at home), 15.4% versus 8.0%; moderate disability, 23.4% versus 19.7%; and good recovery, 4.0% versus 6.9%. At 12 months, the GOS-E distributions were as follows: death, 30.4% among 194 surgical patients versus 52.0% among 179 medical patients; vegetative state, 6.2% versus 1.7%; lower severe disability, 18.0% versus 14.0%; upper severe disability, 13.4% versus 3.9%; moderate disability, 22.2% versus 20.1%; and good recovery, 9.8% versus 8.4%. Surgical patients had fewer hours than medical patients with intracranial pressure above 25 mm Hg after randomization (median, 5.0 vs. 17.0 hours; P<0.001) but had a higher rate of adverse events (16.3% vs. 9.2%, P=0.03). CONCLUSIONS At 6 months, decompressive craniectomy in patients with traumatic brain injury and refractory intracranial hypertension resulted in lower mortality and higher rates of vegetative state, lower severe disability, and upper severe disability than medical care. The rates of moderate disability and good recovery were similar in the two groups. (Funded by the Medical Research Council and others; RESCUEicp Current Controlled Trials number, ISRCTN66202560 .).
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Affiliation(s)
- Peter J Hutchinson
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Angelos G Kolias
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Ivan S Timofeev
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Elizabeth A Corteen
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Marek Czosnyka
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Jake Timothy
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Ian Anderson
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Diederik O Bulters
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Antonio Belli
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - C Andrew Eynon
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - John Wadley
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - A David Mendelow
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Patrick M Mitchell
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Mark H Wilson
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Giles Critchley
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Juan Sahuquillo
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Andreas Unterberg
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Franco Servadei
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Graham M Teasdale
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - John D Pickard
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - David K Menon
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Gordon D Murray
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
| | - Peter J Kirkpatrick
- From the Division of Neurosurgery, Department of Clinical Neurosciences (P.J.H., A.G.K., I.S.T., E.A.C., M.C., J.D.P., P.J.K.), and the Division of Anaesthesia (D.K.M.), Addenbrooke's Hospital and University of Cambridge, Cambridge, the Department of Neurosurgery, Leeds General Infirmary, Leeds (J.T., I.A.), the Department of Neurosurgery (D.O.B.) and Neurosciences Intensive Care Unit (C.A.E.), Wessex Neurological Centre, University Hospital Southampton, Southampton, the NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham (A.B.), the Department of Neurosurgery, St. Bartholomew's and Royal London Hospital (J.W.), and the Department of Neurosurgery, St. Mary's Hospital (M.H.W.), London, the Institute of Neuroscience, Neurosurgical Trials Group, Newcastle University (A.D.M.), and the Department of Neurosurgery, Royal Victoria Infirmary (P.M.M.), Newcastle upon Tyne, Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals, Haywards Heath (G.C.), the Institute of Health and Wellbeing, University of Glasgow, Glasgow (G.M.T.), and Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, University of Edinburgh, Edinburgh (G.D.M.) - all in the United Kingdom; the Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona (J.S.); the Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany (A.U.); and the Neurosurgery-Neurotraumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Arcispedale S. Maria Nuova-IRCCS Reggio Emilia, University of Parma, Parma, Italy (F.S.)
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Abstract
Traumatic brain injury (TBI) represents a wide spectrum of disease and disease severity. Because the primary brain injury occurs before the patient enters the health care system, medical interventions seek principally to prevent secondary injury. Anesthesia teams that provide care for patients with TBI both in and out of the operating room should be aware of the specific therapies and needs of this unique and complex patient population.
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Honeybul S, Ho KM. Predicting long-term neurological outcomes after severe traumatic brain injury requiring decompressive craniectomy: A comparison of the CRASH and IMPACT prognostic models. Injury 2016; 47:1886-92. [PMID: 27157985 DOI: 10.1016/j.injury.2016.04.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 03/26/2016] [Accepted: 04/13/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Predicting long-term neurological outcomes after severe traumatic brain (TBI) is important, but which prognostic model in the context of decompressive craniectomy has the best performance remains uncertain. METHODS This prospective observational cohort study included all patients who had severe TBI requiring decompressive craniectomy between 2004 and 2014, in the two neurosurgical centres in Perth, Western Australia. Severe disability, vegetative state, or death were defined as unfavourable neurological outcomes. Area under the receiver-operating-characteristic curve (AUROC) and slope and intercept of the calibration curve were used to assess discrimination and calibration of the CRASH (Corticosteroid-Randomisation-After-Significant-Head injury) and IMPACT (International-Mission-For-Prognosis-And-Clinical-Trial) models, respectively. RESULTS Of the 319 patients included in the study, 119 (37%) had unfavourable neurological outcomes at 18-month after decompressive craniectomy for severe TBI. Both CRASH (AUROC 0.86, 95% confidence interval 0.81-0.90) and IMPACT full-model (AUROC 0.85, 95% CI 0.80-0.89) were similar in discriminating between favourable and unfavourable neurological outcome at 18-month after surgery (p=0.690 for the difference in AUROC derived from the two models). Although both models tended to over-predict the risks of long-term unfavourable outcome, the IMPACT model had a slightly better calibration than the CRASH model (intercept of the calibration curve=-4.1 vs. -5.7, and log likelihoods -159 vs. -360, respectively), especially when the predicted risks of unfavourable outcome were <80%. CONCLUSIONS Both CRASH and IMPACT prognostic models were good in discriminating between favourable and unfavourable long-term neurological outcome for patients with severe TBI requiring decompressive craniectomy, but the calibration of the IMPACT full-model was better than the CRASH model.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Western Australia, Australia; Department of Neurosurgery, Royal Perth Hospital, Western Australia, Australia.
| | - Kwok M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia
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Beer-Furlan A, Paiva WS, de Andrade AF, Figueiredo EG. The Bone Flap Dilemma in Acute Subdural Hematoma Surgery. World Neurosurg 2016; 94:559-560. [PMID: 27476689 DOI: 10.1016/j.wneu.2016.07.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- André Beer-Furlan
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Wellingson Silva Paiva
- Department of Neurology, Division of Neurosurgery, University of São Paulo Medical School (FMUSP), São Paulo, Brazil
| | - Almir Ferreira de Andrade
- Department of Neurology, Division of Neurosurgery, University of São Paulo Medical School (FMUSP), São Paulo, Brazil
| | - Eberval Gadelha Figueiredo
- Department of Neurology, Division of Neurosurgery, University of São Paulo Medical School (FMUSP), São Paulo, Brazil
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Roberts SAG, Toman E, Belli A, Midwinter MJ. Decompressive craniectomy and cranioplasty: experience and outcomes in deployed UK military personnel. Br J Neurosurg 2016; 30:529-35. [DOI: 10.1080/02688697.2016.1208807] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Uncertainty, conflict and consent: revisiting the futility debate in neurotrauma. Acta Neurochir (Wien) 2016; 158:1251-7. [PMID: 27143027 DOI: 10.1007/s00701-016-2818-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
Abstract
The concept of futility has been debated for many years, and a precise definition remains elusive. This is not entirely unsurprising given the increasingly complex and evolving nature of modern medicine. Progressively more complex decisions are required when considering increasingly sophisticated diagnostic and therapeutic interventions. Allocating resources appropriately amongst a population whose expectations continue to increase raises a number of ethical issues not least of which are the difficulties encountered when consideration is being given to withholding "life-preserving" treatment. In this discussion we have used decompressive craniectomy for severe traumatic brain injury as a clinical example with which to frame an approach to the concept. We have defined those issues that initially lead us to consider futility and thereafter actually provoke a significant discussion. We contend that these issues are uncertainty, conflict and consent. We then examine recent scientific advances in outcome prediction that may address some of the uncertainty and perhaps help achieve consensus amongst stakeholders. Whilst we do not anticipate that this re-framing of the idea of futility is applicable to all medical situations, the approach to specify patient-centred benefit may assist those making such decisions when patients are incompetent to participate.
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Fletcher TL, Wirthl B, Kolias AG, Adams H, Hutchinson PJA, Sutcliffe MPF. Modelling of Brain Deformation After Decompressive Craniectomy. Ann Biomed Eng 2016; 44:3495-3509. [PMID: 27278343 PMCID: PMC5112297 DOI: 10.1007/s10439-016-1666-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 05/28/2016] [Indexed: 02/05/2023]
Abstract
Hyperelastic finite element models, with either an idealized cylindrical geometry or with realistic craniectomy geometries, were used to explore clinical issues relating to decompressive craniectomy. The potential damage in the brain tissue was estimated by calculating the volume of material exceeding a critical shear strain. Results from the idealized model showed how the potentially damaged volume of brain tissue increased with an increasing volume of brain tissue herniating from the skull cavity and with a reduction in craniectomy area. For a given herniated volume, there was a critical craniectomy diameter where the volume exceeding a critical shear strain fell to zero. The effects of details at the craniectomy edge, specifically a fillet radius and a chamfer on the bone margin, were found to be relatively slight, assuming that the dura is retained to provide effective protection. The location in the brain associated with volume expansion and details of the material modeling were found to have a relatively modest effect on the predicted damage volume. The volume of highly sheared material in the realistic models of the craniectomy varied roughly in line with differences in the craniectomy area.
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Affiliation(s)
- Tim L Fletcher
- Department of Engineering, University of Cambridge, Cambridge, CB2 1PZ, UK
| | - Barbara Wirthl
- Department of Engineering, University of Cambridge, Cambridge, CB2 1PZ, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Peter J A Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, CB2 0QQ, UK
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Gregson BA, Rowan EN, Francis R, McNamee P, Boyers D, Mitchell P, McColl E, Chambers IR, Unterberg A, Mendelow AD. Surgical Trial In Traumatic intraCerebral Haemorrhage (STITCH): a randomised controlled trial of Early Surgery compared with Initial Conservative Treatment. Health Technol Assess 2016; 19:1-138. [PMID: 26346805 DOI: 10.3310/hta19700] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND While it is accepted practice to remove extradural (EDH) and subdural haematomas (SDH) following traumatic brain injury, the role of surgery in parenchymal traumatic intracerebral haemorrhage (TICH) is controversial. There is no evidence to support Early Surgery in this condition. OBJECTIVES There have been a number of trials investigating surgery for spontaneous intracerebral haemorrhage but none for TICH. This study aimed to establish whether or not a policy of Early Surgery for TICH improves outcome compared with a policy of Initial Conservative Treatment. DESIGN This was an international multicentre pragmatic parallel group trial. Patients were randomised via an independent telephone/web-based randomisation service. SETTING Neurosurgical units in 59 hospitals in 20 countries registered to take part in the study. PARTICIPANTS The study planned to recruit 840 adult patients. Patients had to be within 48 hours of head injury with no more than two intracerebral haematomas greater than 10 ml. They did not have a SDH or EDH that required evacuation or any severe comorbidity that would mean they could not achieve a favourable outcome if they made a complete recovery from their head injury. INTERVENTIONS Patients were randomised to Early Surgery within 12 hours or to Initial Conservative Treatment with delayed evacuation if it became clinically appropriate. MAIN OUTCOME MEASURES The Extended Glasgow Outcome Scale (GOSE) was measured at 6 months via a postal questionnaire. The primary outcome was the traditional dichotomised split into favourable outcome (good recovery or moderate disability) and unfavourable outcome (severe disability, vegetative, dead). Secondary outcomes included mortality and an ordinal assessment of Glasgow Outcome Scale and Rankin Scale. RESULTS Patient recruitment began in December 2009 but was halted by the funding body because of low UK recruitment in September 2012. In total, 170 patients were randomised from 31 centres in 13 countries: 83 to Early Surgery and 87 to Initial Conservative Treatment. Six-month outcomes were obtained for 99% of 168 eligible patients (82 Early Surgery and 85 Initial Conservative Treatment patients). Patients in the Early Surgery group were 10.5% more likely to have a favourable outcome (absolute benefit), but this difference did not quite reach statistical significance because of the reduced sample size. Fifty-two (63%) had a favourable outcome with Early Surgery, compared with 45 (53%) with Initial Conservative Treatment [odds ratio 0.65; 95% confidence interval (CI) 0.35 to 1.21; p = 0.17]. Mortality was significantly higher in the Initial Conservative Treatment group (33% vs. 15%; absolute difference 18.3%; 95% CI 5.7% to 30.9%; p = 0.006). The Rankin Scale and GOSE were significantly improved with Early Surgery using a trend analysis (p = 0.047 and p = 0.043 respectively). CONCLUSIONS This is the first ever trial of surgery for TICH and indicates that Early Surgery may be a valuable tool in the treatment of TICH, especially if the Glasgow Coma Score is between 9 and 12, as was also found in Surgical Trial In spontaneous intraCerebral Haemorrhage (STICH) and Surgical Trial In spontaneous lobar intraCerebral Haemorrhage (STICH II). Further research is clearly warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN 19321911. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 70. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Barbara A Gregson
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Elise N Rowan
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Richard Francis
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Patrick Mitchell
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Iain R Chambers
- South Tees Hospitals Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, D-69120 Heidelberg, Germany
| | - A David Mendelow
- Neurosurgical Trials Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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Wang JW, Li JP, Song YL, Tan K, Wang Y, Li T, Guo P, Li X, Wang Y, Zhao QH. Decompressive craniectomy in neurocritical care. J Clin Neurosci 2016; 27:1-7. [DOI: 10.1016/j.jocn.2015.06.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 06/16/2015] [Accepted: 06/20/2015] [Indexed: 10/22/2022]
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Kolias AG, Adams H, Timofeev I, Czosnyka M, Corteen EA, Pickard JD, Turner C, Gregson BA, Kirkpatrick PJ, Murray GD, Menon DK, Hutchinson PJ. Decompressive craniectomy following traumatic brain injury: developing the evidence base. Br J Neurosurg 2016; 30:246-50. [PMID: 26972805 PMCID: PMC4841020 DOI: 10.3109/02688697.2016.1159655] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
In the context of traumatic brain injury (TBI), decompressive craniectomy (DC) is used as part of tiered therapeutic protocols for patients with intracranial hypertension (secondary or protocol-driven DC). In addition, the bone flap can be left out when evacuating a mass lesion, usually an acute subdural haematoma (ASDH), in the acute phase (primary DC). Even though, the principle of "opening the skull" in order to control brain oedema and raised intracranial pressure has been practised since the beginning of the 20th century, the last 20 years have been marked by efforts to develop the evidence base with the conduct of randomised trials. This article discusses the merits and challenges of this approach and provides an overview of randomised trials of DC following TBI. An update on the RESCUEicp study, a randomised trial of DC versus advanced medical management (including barbiturates) for severe and refractory post-traumatic intracranial hypertension is provided. In addition, the rationale for the RESCUE-ASDH study, the first randomised trial of primary DC versus craniotomy for adult head-injured patients with an ASDH, is presented.
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Affiliation(s)
- Angelos G Kolias
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Hadie Adams
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Ivan Timofeev
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Marek Czosnyka
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Elizabeth A Corteen
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - John D Pickard
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Carole Turner
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Barbara A Gregson
- b Institute of Neuroscience, Neurosurgical Trials Group , Newcastle University , Newcastle , UK
| | - Peter J Kirkpatrick
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Gordon D Murray
- c Centre for Population Health Sciences, University of Edinburgh , Edinburgh , UK
| | - David K Menon
- d Division of Anaesthesia , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
| | - Peter J Hutchinson
- a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge, Cambridge Biomedical Campus , Cambridge , UK
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Fotakopoulos G, Tsianaka E, Vagkopoulos K, Fountas KN. According to which factors in severe traumatic brain injury craniectomy could be beneficial. Surg Neurol Int 2016; 7:19. [PMID: 26981320 PMCID: PMC4774169 DOI: 10.4103/2152-7806.176671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 12/31/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To investigate the clinical outcome at 101 patients undergoing decompressive craniectomy (DC) after severe traumatic brain injury (TBI). METHODS Age, Glasgow Coma Scale (GCS) at the time of intubation, and the intraoperative intracranial pressure (ICP) were recorded. Formal DC was performed in all cases and the square surface of bone flap was calculated in cm(2) based on the length and the width from computed tomography scan. RESULTS The difference of good neurological recovery (Glasgow outcome score 4-5), between patients with ICP ≤20 mmHg, GCS ≥5, age ≤60 years, and bone flap ≥130 cm(2) and those with ICP >20 mmHg, GCS <5, age >60 years, and bone flap <130 cm(2), was statistically significant. CONCLUSION Although the application of DC in severe TBI is controversial and the population in this study is small, our study demonstrates the threshold of the specific factors (patient age, ICP and GCS on the day of the surgery and the size of the bone flap) which may help in the decision of performing DC. Furthermore, this study proves that the different combinations and mainly at the same time involvement of all prognostic parameters (age <60, GCS <5, bone flap ≥130 cm(2), and ICP ≤20 at time of DC surgery) allow a better outcome.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece,Corresponding author
| | - Eleni Tsianaka
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Konstantinos Vagkopoulos
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece,Center for Research and Technology of Thessaly, 38500 Larissa, Greece
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Kinoshita T, Yoshiya K, Fujimoto Y, Kajikawa R, Kiguchi T, Hara M, Wakayama A, Yoshimine T. Decompressive Craniectomy in Conjunction With Evacuation of Intracranial Hemorrhagic Lesions Is Associated With Worse Outcomes in Elderly Patients With Traumatic Brain Injury: A Propensity Score Analysis. World Neurosurg 2016; 89:187-92. [PMID: 26851740 DOI: 10.1016/j.wneu.2016.01.071] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 01/17/2016] [Accepted: 01/19/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND When it comes to evacuating intracranial hemorrhagic lesions in patients with traumatic brain injury (TBI), neurosurgeons perform either a craniotomy or a decompressive craniectomy (DC). The aim of the present study was to estimate the impact of DC on outcomes in elderly patients. METHODS This retrospective cohort study, conducted in a neurosurgical institute in Japan from April 2009 to June 2014, included 91 consecutive patients with TBI (aged 60 years or older) who underwent evacuation of intracranial hemorrhagic lesions. Patients were divided into 2 groups: craniotomy only or DC. We set the primary endpoint as an unfavorable outcome (death or vegetative state), as evaluated on the Glasgow Outcome Scale at 6 months after injury. The secondary endpoints included existence of delayed hemorrhage and occurrence of hydrocephalus requiring shunt placement. The inverse probability of treatment weighting method was used to develop a propensity model to adjust for baseline imbalances between groups. RESULTS The DC group exhibited greater severity both in clinical and computed tomography findings according to baseline characteristics. After we adjusted for these differences by inverse probability of treatment weighting using the propensity score, DC was significantly associated with unfavorable outcomes (adjusted odds ratio, 8.00; 95% confidential interval, 2.30-27.84; P = 0.002) and delayed hemorrhage (adjusted odds ratio, 13.42; 95% confidential interval, 1.52-118.89; P = 0.022). There was no significant difference in the occurrence of hydrocephalus requiring shunt placement. CONCLUSIONS DC in conjunction with evacuation of intracranial hemorrhagic lesions was associated with worse functional outcome in elderly patients with TBI.
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Affiliation(s)
- Takahiro Kinoshita
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Japan; Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan.
| | - Kazuhisa Yoshiya
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasunori Fujimoto
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Japan
| | - Ryuichiro Kajikawa
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Japan
| | - Takeyuki Kiguchi
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Masahiko Hara
- Department of Clinical Epidemiology and Biostatistics, Osaka University Graduate School of Medicine, Suita, Japan; Department of Medical Innovation, Osaka University Hospital, Suita, Japan
| | - Akatsuki Wakayama
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Japan
| | - Toshiki Yoshimine
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
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Zhao HX, Liao Y, Xu D, Wang QP, Gan Q, You C, Yang CH. Prospective randomized evaluation of therapeutic decompressive craniectomy in severe traumatic brain injury with mass lesions (PRECIS): study protocol for a controlled trial. BMC Neurol 2016; 16:1. [PMID: 26727957 PMCID: PMC4700654 DOI: 10.1186/s12883-015-0524-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 12/29/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND For cases of severe traumatic brain injury, during primary operation, neurosurgeons usually face a dilemma of whether or not to remove the bone flap after mass lesion evacuation. Decompressive craniectomy, which involves expansion of fixed cranial cavity, is used to treat intra-operative brain swelling and post-operative malignant intracranial hypertension. However, due to indefinite indication, the decision to perform this procedure heavily relies on personal experiences. In addition, decompressive craniectomy is associated with various complications, and the procedure lacks strong evidence of better outcomes. In the present study, we designed a prospective, randomized, controlled trial to clarify the effect of decompressive craniectomy in severe traumatic brain injury patients with mass lesions. METHODS PRECIS is a prospective, randomized, assessor-blind, single center clinical trial. In this trial, 336 patients with traumatic mass lesions will be randomly allocated to a therapeutic decompressive craniectomy group or a prophylactic decompressive craniectomy group. In the therapeutic decompressive craniectomy group, the bone flap will be removed or replaced depending on the emergence of brain swelling. In the prophylactic decompressive craniectomy group, the bone flap will be removed after mass lesion evacuation. A stepwise management of intracranial pressure will be provided according to the Brain Trauma Foundation guidelines. Salvage decompressive craniectomy will be performed for craniotomy patients once there is evidence of imaging deterioration and post-operative malignant intracranial hypertension. Participants will be assessed at 1, 6 and 12 months after randomization. The primary endpoint is favorable outcome according to the Extended Glasgow Outcome Score (5-8) at 12 months. The secondary endpoints include quality of life measured by EQ-5D, mortality, complications, intracranial pressure and cerebral perfusion pressure control and incidence of salvage craniectomy in craniotomy patients at each investigation time point. DISCUSSION This study will provide evidence to optimize primary decompressive craniectomy application and assess outcomes and risks for mass lesions in severe traumatic brain injury. TRIAL REGISTRATION ISRCTN20139421.
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Affiliation(s)
- He-xiang Zhao
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Yi Liao
- Department of Neuro-intensive care unit, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Ding Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Qiang-ping Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Qi Gan
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Chao-hua Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
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Aertker BM, Bedi S, Cox CS. Strategies for CNS repair following TBI. Exp Neurol 2016; 275 Pt 3:411-426. [DOI: 10.1016/j.expneurol.2015.01.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/08/2015] [Accepted: 01/22/2015] [Indexed: 12/20/2022]
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Sauvigny T, Göttsche J, Vettorazzi E, Westphal M, Regelsberger J. New Radiologic Parameters Predict Clinical Outcome after Decompressive Craniectomy. World Neurosurg 2015; 88:519-525.e1. [PMID: 26548831 DOI: 10.1016/j.wneu.2015.10.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 10/18/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is an established part of the management of patients with increased intracranial pressure due to malignant middle cerebral artery (MCA) infarction or traumatic brain injury (TBI). The aim of this study was to determine prognostic radiologic parameters regarding the functional outcome of patients with increased intracranial pressure (ICP) undergoing DC. Special focus was put on the potential differences between malignant MCA infarction and TBI. METHODS A total of 113 patients were analyzed for their clinical course where preoperative and postoperative radiologic features in computed tomography (CT) scans were correlated to the clinical outcome assessed by the Glasgow Outcome Scale. The difference between presurgical and postsurgical midline shift (ΔMLS) and the ratio between the diameter of the affected and contralateral hemisphere (HDratio) in presurgical and postsurgical CT scans were calculated. RESULTS ΔMLS (MCA infarction group) and postsurgical HDratio (TBI group) were found to be highly correlating with the clinical outcome on Spearman-correlation testing and underwent further analysis using a binary logistic regression model to evaluate their prognostic value on the outcome, which showed the predictive power of ΔMLS in malignant MCA infarction patients (odds ratio [OR] 0.715; confidence interval [CI] 0.551-0.865). Postsurgical HDratio correlated significantly (OR 0.620; CI 0.384-0.901) with the outcome in the TBI group. CONCLUSION ΔMLS is an objectifiable parameter, predicting outcome in malignant MCA infarction. In contrast, ΔMLS was of no predictive value in TBI patients. Here postsurgical HDratio serves as a strong predictor of clinical outcome. We recommend applying postsurgical HDratio to TBI patients in order to estimate their clinical outcome and adjust treatment.
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Affiliation(s)
- Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Zhao HX, Liao Y, Xu D, Wang QP, Gan Q, You C, Yang CH. The value of intraoperative intracranial pressure monitoring for predicting re-operation using salvage decompressive craniectomy after craniotomy in patients with traumatic mass lesions. BMC Surg 2015; 15:111. [PMID: 26467905 PMCID: PMC4605088 DOI: 10.1186/s12893-015-0100-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 10/10/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The risk factors of predicting the need for postoperative decompressive craniectomy due to intracranial hypertension after primary craniotomy remain unclear. This study aimed to investigate the value of intraoperative intracranial pressure (ICP) monitoring in predicting re-operation using salvage decompressive craniectomy (SDC). METHODS From January 2008 to October 2014, we retrospectively reviewed 284 patients with severe traumatic brain injury (STBI) who underwent craniotomy for mass lesion evacuation without intraoperative brain swelling. Intraoperative ICP was documented at the time of initial craniotomy and then again after the dura was sutured. SDC was used when postoperative ICP was continually higher than 25 mmHg for 1 h without a downward trend. Univariate and multivariate analyses were applied to both initial demographic and radiographic features to identify risk factors of SDC requirement. RESULTS Of 284, 41 (14.4%) patients who underwent SDC had a higher Initial ICP than those who didn't (38.1 ± 9.2 vs. 29.3 ± 8.1 mmHg, P < 0.001), but there was no difference in ICP after the dura was sutured. The factors which have significant effects on SDC are higher initial ICP [odds ratio (OR): 1.100, 95% confidence interval (CI): 1.052-1.151, P < 0.001], older age (OR: 1.039, 95% CI: 1.002-1.077, P = 0.039), combined lesions (OR: 3.329, 95% CI: 1.199-9.244, P = 0.021) and early hypotension (OR: 2.524, 95% CI: 1.107-5.756, P = 0.028). The area under the curve of multivariate regression model was 0.771. CONCLUSIONS The incidence of re-operation using SDC after craniotomy was 14.4%. The independent risk factors of SDC requirement are initial ICP, age, early hypotension and combined lesions.
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Affiliation(s)
- He-xiang Zhao
- />Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan 610041 P. R. China
| | - Yi Liao
- />Department of Neuro-intensive care unit, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan 610041 P. R. China
| | - Ding Xu
- />Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan 610041 P. R. China
| | - Qiang-ping Wang
- />Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan 610041 P. R. China
| | - Qi Gan
- />Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan 610041 P. R. China
| | - Chao You
- />Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan 610041 P. R. China
| | - Chao-hua Yang
- />Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan 610041 P. R. China
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Wang R, Li M, Gao WW, Guo Y, Chen J, Tian HL. Outcomes of Early Decompressive Craniectomy Versus Conventional Medical Management After Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2015; 94:e1733. [PMID: 26512565 PMCID: PMC4985379 DOI: 10.1097/md.0000000000001733] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This meta-analysis examined whether early decompressive craniectomy (DC) can improve control of intracranial pressure (ICP) and mortality in patients with traumatic brain injury (TBI).Medline, Cochrane, EMBASE, and Google Scholar databases were searched until May 14, 2015, using the following terms: traumatic brain injury, refractory intracranial hypertension, high intracranial pressure, craniectomy, standard care, and medical management. Randomized controlled trials in which patients with TBI received DC and non-DC medical treatments were included.Of the 84 articles identified, 8 studies were selected for review, with 3 randomized controlled trials s having a total of 256 patients (123 DCs, 133 non-DCs) included in the meta-analysis. Patients receiving DC had a significantly greater reduction of ICP and shorter hospital stay. They also seemed to have lower odds of death than patients receiving only medical management, but the P value did not reach significance (pooled odds ratio 0.531, 95% confidence interval 0.209-1.350, Z = 1.95, P = 0.183) with respect to the effect on overall mortality; a separate analysis of 3 retrospective studies yielded a similar result.Whereas DC might effectively reduce ICP and shorten hospital stay in patients with TBI, its effect in decreasing mortality has not reached statistical significance.
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Affiliation(s)
- Ren Wang
- From the Department of Neurosurgery (RW, W-WG, YG, JC, H-LT); and Department of Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China (ML)
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