Decompressive Craniectomy for Severe Traumatic Brain Injury: A Systematic Review

Efficacy of decompressive craniectomy: A retrospective case series study with 321 patients and an update on controversies

Decompressive craniectomy (DC) is considered a cornerstone in the management of refractory intracranial hypertension. For decades, DC was known as an occasionally lifesaving procedure; however, it was associated with numerous severe complications. The present study is a single-center retrospective case series study on with 321 patients who underwent DC between January, 2010 and December, 2020. All patients were divided into four groups as follows: Group A included patients who suffered from a space-occupying middle cerebral artery (MCA) ischemic event; group B included individuals who developed intracerebral hemorrhage; group C included patients admitted for traumatic brain injury; and group D included patients with other neurosurgical entities that underwent DC, such as subarachnoid hemorrhage, tumors, brain abscess and cerebral ventricular sinus thrombosis events. The present study enrolled a total of 321 patients who underwent DC. Group A included 52 out of the 321 (16.1%) patients, group B included 51 (15.8%) patients, group C included 164 (51.0%) patients, and group D included 54 (16.8%) patients. Of the 321 patients, 235 (73.2%) were males, and the median age was 53.7 years. Multivariate analysis revealed that only the group A parameter was an independent factor associated with a Glasgow outcome scale score >2 during follow-up (P<0.05). On the whole, the results of the present study suggest that among patients who underwent DC with different neurological entities, those who had experienced MCA events had more favorable outcomes.

Decompressive craniectomy incisions: all roads lead to bone

INTRODUCTION

Decompressive craniectomy and craniotomy are among the most common procedures in Neurosurgery. In recent years, increased attention has focused on the relationships between incision type, extent of decompression, vascular supply to the scalp, cosmetic outcomes, and complications. Here, we review the current literature on scalp incisions for large unilateral front-temporo-parietal craniotomies and craniectomies.

METHODS

Publications in the past 50 years on scalp incisions used for front-temporo-parietal craniectomies/craniotomies were reviewed. Only full texts were considered in the final analysis. A total of 27 studies that met the criteria were considered for the final manuscript. PRISMA guidelines were adopted for this study.

RESULTS

Five main incision types have been described. In addition to the question mark incision, other common incisions include the T-Kempe, developed to obtain wide access to the skull, the retroauricular incision, designed to spare the occipital branch, as well as the N-shaped and cloverleaf incisions which integrate with pterional approaches. Advantages and drawbacks, integration with existing incisions, relationships with the main arteries, cosmetic outcomes, and risks of wound complications including dehiscence, necrosis, and infection were assessed.

DISCUSSION

The reverse-question mark incision, despite being a mainstay of trauma neurosurgery, can place the vascular supply to the scalp at risk and favor wound dehiscence and infection. Several incisions, such as the T-Kempe, retroauricular, N-shaped, and cloverleaf approaches have been developed to preserve the main vessels supplying the scalp. Incision choice needs to be carefully weighted based on the patient's anatomy, position and size of main vessels, risk of wound dehiscence, and desired volume of decompression.

Health-related quality of life measures in patients undergoing decompressive craniectomy for severe traumatic brain injury: a 6-year follow-up analysis

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.

Role of decompressive craniectomy in the management of acute ischemic stroke (Review)

The application of decompressive craniectomy (DC) is thoroughly documented in the management of brain edema, particularly following traumatic brain injury. However, an increasing amount of concern is developing among the universal medical community as regards the application of DC in the treatment of other causes of brain edema, such as subarachnoid hemorrhage, cerebral hemorrhage, sinus thrombosis and encephalitis. Managing stroke continues to remain challenging, and demands the aggressive and intensive consulting of a number of medical specialties. Middle cerebral artery (MCA) infarcts, which consist of 1-10% of all supratentorial infarcts, are often associated with mass effects, and high mortality and morbidity rates. Over the past three decades, a number of neurosurgical medical centers have reported their experience with the application of DC in the treatment of malignant MCA infarction with varying results. In addition, over the past decade, major efforts have been dedicated to multicenter randomized clinical trials. The present study reviews the pertinent literature to outline the use of DC in the management of malignant MCA infarction. The PubMed database was systematically searched for the following terms: 'Malignant cerebral infarction', 'surgery for stroke', 'DC for cerebral infarction', and all their combinations. Case reports were excluded from the review. The articles were categorized into a number of groups; the majority of these were human clinical studies, with a few animal experimental clinical studies. The surgical technique involved was DC, or hemicraniectomy. Other aspects that were included in the selection of articles were methodological characteristics and the number of patients. The multicenter randomized trials were promising. The mortality rate has unanimously decreased. As for the functional outcome, different scales were employed; the Glasgow Outcome Scale Extended was not sufficient; the Modified Rankin Scale and Bathel index, as well as other scales, were applied. Other aspects considered were demographics, statistics and the very interesting radiological ones. There is no doubt that DC decreases mortality rates, as shown in all clinical trials. Functional outcome appears to be the goal standard in modern-era neurosurgery, and quality of life should be further discussed among the medical community and with patient consent.

Comparing Outcomes for Emergent Cranial Neurosurgical Procedures Performed "During Hours" and "After Hours"

OBJECTIVE

Surgery performed at night and on weekends is thought to be associated with increased complications. However, the impact of time of day on outcomes has not been studied within cranial neurosurgery. We aim to determine if there are differences in outcomes for cranial neurosurgery performed after hours (AH) compared with during hours (DH).

METHODS

We performed a single-center retrospective study of cranial neurosurgery patients who underwent emergent surgery from January 2015 through December 2019. Surgery was considered DH if the incision occurred between 8 am and 5 pm Monday through Friday. We assessed outcome measures for differences between operations performed DH or AH.

RESULTS

Three-hundred and ninety-three patients (114 DH, 279 AH) underwent surgery. There was a lower rate of return to the operating room within 30 days for AH (8.6%) compared with DH (14.0%), P = 0.03, on multivariate analysis. There were no significant differences in length of operation, estimated blood loss, improvement in Glasgow Coma Scale, intensive care unit and total hospital length of stay, 30-day readmission, 30-day mortality, and in-hospital mortality for cases performed DH compared with AH. Further subgroup analyses were performed for patients who underwent immediate surgery for subdural hematomas, with no differences noted in outcomes on multivariate analysis.

CONCLUSIONS

This study suggests that operating AH does not appear to negatively impact outcomes when compared with operating DH, in cases of cranial neurosurgical emergencies. Further study assessing the impact on elective neurosurgical cases is required.

Low-Cost Wound Healing Protocol Reduces Infection and Reoperation Rates After Cranioplasty: A Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

Cranioplasty infections are a common and expensive problem associated with significant morbidity. Our objective was to determine whether a wound healing protocol after cranioplasty reduced the rate of infections and to determine the value of this intervention.

METHODS

This is a single-institution retrospective chart review of 2 cohorts of cranioplasty patients over 12 years. The wound healing protocol, consisting of vitamin and mineral supplementation, fluid supplementation, and oxygen support, was instituted for all patients aged older than 15 years undergoing cranioplasty. We retrospectively reviewed the charts of all patients over the study period and compared outcomes before and after protocol institution. Outcomes included surgical site infection, return to operating room within 30 days, and cranioplasty explant. Cost data were collected from the electronic medical record. We included 291 cranioplasties performed before the wound healing protocol and 68 postprotocol.

RESULTS

Baseline demographics and comorbidities were comparable between preprotocol and postprotocol groups. Odds of takeback to operating room within 30 days were the same before and after the wound healing protocol (odds ratio [OR] 2.21 [95% CI 0.76-6.47], P = .145). Odds of clinical concern for surgical site infection were significantly higher in the preprotocol group (OR 5.21 [95% CI 1.22-22.17], P = .025). Risk of washout was higher in the preprotocol group (HR 2.86 [95% CI 1.08-7.58], P = .035). Probability of cranioplasty flap explant was also significantly higher in the preprotocol group (OR 4.70 [95% CI 1.10-20.05], P = .036). The number needed to treat to prevent 1 cranioplasty infection was 24.

CONCLUSION

A low-cost wound healing protocol was associated with reduced rate of infections after cranioplasty with concomitant reduction in reoperations for washout, saving the health care system more than $50,000 per 24 patients. Prospective study is warranted.

Direct to Operating Room for Decompressive Craniotomy/Craniectomy in Patients With Traumatic Brain Injury

BACKGROUND

Emergent decompressive craniotomy/craniectomy can be a lifesaving surgical intervention for select patients with traumatic brain injury. Prompt management is critical as early decompression can impact traumatic brain injury outcomes.

OBJECTIVE

This study aims to describe the feasibility and clinical impact of a new pathway for transporting patients with severe traumatic brain injury directly to the operating room from the trauma bay for decompressive craniotomy/craniectomy.

METHODS

This is a retrospective cohort preintervention and postintervention study of severe traumatic brain injury patients undergoing decompressive craniectomy/craniotomy at a Midwestern U.S. Level I trauma center between 2016 and 2022. In the new pathway, the in-house trauma surgeon takes the patient directly to the operating room with the neurosurgery advanced practice provider to drape and prepare the patient for surgery while the neurosurgeon is en route to the hospital.

RESULTS

A total of 44 patients were studied, five (5/44, 11.4%) of which were in the preintervention group and 39 (39/44, 88.6%) in the postintervention group. The median arrival-to-operating room time was shorter in the postintervention cohort (1.4 hr) than in the preintervention cohort (1.5 hr). In examining night shifts only, the preintervention cohort had shorter arrival-to-operating room times (1.2 hr) than the postintervention cohort (1.5 hr).

CONCLUSION

The study demonstrated that the new pathway is feasible and expedites patient transport to the operating room while awaiting the arrival of the on-call neurosurgeon.

Recent changes in practice patterns and outcomes in patients with severe traumatic brain injury

BACKGROUND

Despite recent advances in the management of severe traumatic brain injury, the role of decompressive craniectomy remains unclear. The purpose of this study was to compare practice patterns and patient outcomes between 2 study periods over the past decade.

METHODS

This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Project database. We included patients (age ≥18 years) with isolated severe traumatic brain injury. The patients were divided into the early (2013-2014) and late (2017-2018) groups. The primary outcome was the rate of craniectomy, and secondary outcomes included in-hospital mortality and discharge disposition. A subgroup analysis of patients undergoing intracranial pressure monitoring was also performed. A multivariable logistic regression analysis assessed the association between the early/late period and study outcomes.

RESULTS

A total of 29,942 patients were included. In the logistic regression analysis, the late period was associated with decreased use of craniectomy (odds ratio: 0.58, P < .001). Although the late period was associated with higher in-hospital mortality (odds ratio: 1.10, P = .013), it was also associated with a higher likelihood of discharge to home/rehab (odds ratio: 1.61, P < .001). Similarly, the subgroup analysis of patients with intracranial pressure monitoring showed that the late period was associated with a lower craniectomy rate (odds ratio: 0.26, P < .001) and a higher likelihood of discharge to home/rehab (odds ratio:1.98, P < .001).

CONCLUSION

The use of craniectomy for severe traumatic brain injury has decreased over the study period. Although further studies are warranted, these trends may reflect recent changes in the management of patients with severe traumatic brain injury.

Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head: A Department of Defense Trauma Registry and ACS TQIP-matched Study

OBJECTIVE

The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations.

BACKGROUND

Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma.

METHODS

This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database.

RESULTS

A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013).

CONCLUSIONS

Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population.

LEVEL OF EVIDENCE

Level III-therapeutic.

Ultra-High-Molecular-Weight Polyethylene Merlon Shape: Novel Fixation of Artificial Bone for Cranioplasty

BACKGROUND

Cranioplasty is a surgical procedure widely performed for repairing cranial defects caused by external decompression surgery for cerebrovascular disease or traumatic brain injury. We devised a new cranioplasty method using artificial bone made up of ultra-high molecular-weight polyethylene, with serrated wings on the edge. We named this newly designed artificial bone as Merlon shape.

OBJECTIVE

To describe our initial experience with the Merlon shape and evaluate its usefulness and safety in cranioplasty.

METHODS

The serrated wings of the Merlon shape were preoperatively designed for solid fixation and improving cosmetic results by reducing the thickness of the artificial bone. We evaluated 25 patients who underwent cranioplasty with the Merlon shape between December 2018 and December 2021. The causes of bone defects in these patients (male: 9, female: 16; median age: 62 years) were subarachnoid hemorrhage (n = 14), cerebral infarction (n = 8), and traumatic brain injury (n = 3).

RESULTS

There were no postoperative adverse events such as infection, bone resorption, implant exposure, or graft sinking in 24 patients during an average follow-up period of 19 months. One patient experienced acute epidural hemorrhage and required reoperation.

CONCLUSION

This is the first report on the use of the ultra-high molecular-weight polyethylene Merlon shape. Our initial 4-year case series showed good outcomes with this method.

Impact of decompressive craniectomy on functional outcome of severe acquired brain injuries patients, at discharge from intensive inpatient rehabilitation

PURPOSE

Decompressive craniectomy (DC) is a life-saving procedure conducted to treat refractory intracranial hypertension. Although DC reduces mortality of severe Acquired Brain Injury (sABI) survivors, it has been associated with severe long-term disability. This observational study compares functional outcomes at discharge from an Intensive Rehabilitative Unit (IRU) between sABI patients with and without DC.

MATERIAL AND METHODS

sABI patients undergoing DC before entering the Don Gnocchi Foundation IRU were compared with a group of sABI patients who did not undergo DC (No-DC group), after matching it by age, sex, aetiology, time post-onset, and clinical status. Inclusion criteria were: diagnosis of sABI, age 18+, time from the event <90 days.

RESULTS

A total of 87 (DC: 47) patients were included (median age: 60.5 [IQR = 17.47]). The two groups did not differ for admission clinical features except for the tracheostomy presence (more frequent in DC, p < 0.001). No significant differences were also found at discharge. DC group presented a significantly longer length-of-stay than No-DC group (p < 0.001) and a longer time to tracheostomy removal (p = 0.036). DC was not found to influence outcomes as consciousness improvement, tracheostomy removal, oral intake and functional independence.

CONCLUSIONS

sABI patients with DC improved after rehabilitation as much as No-DC patients did but they required a longer stay.Implications for RehabilitationDecompressive craniectomy (DC) is practiced during the acute phase after hemorrhagic, ischemic, traumatic severe brain injury as a life-saving procedure to treat refractory intracranial hypertensionDC has been associated with follow-up severe long-term disability, but no study yet addressed whether DC may affect intensive rehabilitation outcomes.Undergoing a DC is not a negative prognostic factor for achieving rehabilitation goals after a severe acquired brain injuryDC must be taken into account when customizing rehabilitation pathway especially because these patients required a longer time to reach the outcomes.

Characteristics and therapeutic profile of TBI patients who underwent bilateral decompressive craniectomy: experience with 151 cases

Background

Decompressive craniectomy (DC) and intracranial pressure (ICP) monitoring are common approaches to reduce the death rate of Traumatic brain injury (TBI) patients, but the outcomes of these patients are unfavorable, particularly those who receive bilateral DC. The authors discuss their experience using ICP and other potential methods to improve the outcomes of TBI patients who receive bilateral DC.

Methods

Data from TBI patients receiving bilateral DC from Jan. 2008 to Jan. 2022 were collected via a retrospective chart review. Included patients who received unplanned contralateral DC after initial surgery were identified as unplanned secondary surgery (USS) patients. Patients’ demographics and baseline medical status; pre-, intra-, and postoperative events; and follow-up visit outcome data were analyzed.

Results

A total of 151 TBI patients were included. Patients who underwent USS experienced more severe outcomes as assessed using the 3-month modified Rankin Scale score (P = 0.024). In bilateral DC TBI patients, USS were associated with worsen outcomes, moreover, ICP monitoring was able to lower their death rate and was associated with a lower USS incidence. In USS patients, ICP monitoring was not associated with improved outcomes but was able to lower their mortality rate (2/19, 10.5%, vs. 10/25, 40.0%; P = 0.042).

Conclusion

The avoidance of USS may be associated with improved outcomes of TBI patients who underwent bilateral DC. ICP monitoring was a potential approach to lower USS rate in TBI patients, but its specific benefits were uncertain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01046-w.

Primary Decompressive Craniectomy After Traumatic Brain Injury: A Literature Review

Traumatic brain injuries (TBIs) still put a high burden on public health worldwide. Medical and surgical treatment strategies are continuously being studied, but the role and indications of primary decompressive craniectomy (DC) remain controversial. In medically refractory intracranial hypertension after severe traumatic brain injury, secondary decompressive craniectomy is a last resort treatment option to control intracranial pressure (ICP). Randomized controlled studies have been extensively performed on secondary decompressive craniectomy and its role in the management of severe traumatic brain injuries. Indications, prognostic factors, and long-term outcomes in primary decompressive craniectomy during the evacuation of an epidural, subdural, or intracerebral hematoma in the acute phase are still a matter of ongoing research and controversy to this day. Prospective trials have been designed, but the results are yet to be published. In isolated epidural hematoma without underlying brain injury, osteoplastic craniotomy is likely to be sufficient. In acute subdural hematoma (ASDH) with relevant brain swelling and preoperative CT signs such as effaced cisterns, overly proportional midline-shift compared to a relatively small acute subdural hematoma, and accompanying brain contusions as well as pupillary abnormalities, intraventricular hemorrhage, and coagulation disorder, primary decompressive craniectomy is more likely to be of benefit for patients with traumatic brain injury. The role of intracranial pressure monitoring after primary decompressive craniectomy is recommended, but prospective trials are pending. More refined guidelines and hopefully class I evidence will be established with the ongoing trials: randomized evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural hematoma (RESCUE-ASDH), prospective randomized evaluation of decompressive ipsilateral craniectomy for traumatic acute epidural hematoma (PREDICT-AEDH), and pragmatic explanatory continuum indicator summary (PRECIS).

Development and validation of a prediction nomogram for a 6-month unfavorable prognosis in traumatic brain-injured patients undergoing primary decompressive craniectomy: An observational study

Objective

This study was designed to develop and validate a risk-prediction nomogram to predict a 6-month unfavorable prognosis in patients with traumatic brain-injured (TBI) undergoing primary decompressive craniectomy (DC).

Methods

The clinical data of 391 TBI patients with primary DC who were admitted from 2012 to 2020 were reviewed, from which 274 patients were enrolled in the training group, while 117 were enrolled in the internal validation group, randomly. The external data sets containing 80 patients were obtained from another hospital. Independent predictors of the 6-month unfavorable prognosis were analyzed using multivariate logistic regression. Furthermore, a nomogram prediction model was constructed using R software. After evaluation of the model, internal and external validations were performed to verify the efficiency of the model using the area under the receiver operating characteristic curves and the calibration plots.

Results

In multivariate analysis, age(p = 0.001), Glasgow Score Scale (GCS) (p < 0.001), operative blood loss of >750 ml (p = 0.045), completely effaced basal cisterns (p < 0.001), intraoperative hypotension(p = 0.001), and activated partial thromboplastin time (APTT) of >36 (p = 0.012) were the early independent predictors for 6-month unfavorable prognosis in patients with TBI after primary DC. The AUC for the training, internal, and external validation cohorts was 0.93 (95%CI, 0.89–0.96, p < 0.0001), 0.89 (95%CI, 0.82–0.94, p < 0.0001), and 0.90 (95%CI, 0.84–0.97, p < 0.0001), respectively, which indicated that the prediction model had an excellent capability of discrimination. Calibration of the model was exhibited by the calibration plots, which showed an optimal concordance between the predicted 6-month unfavorable prognosis probability and actual probability in both training and validation cohorts.

Conclusion

This prediction model for a 6-month unfavorable prognosis in patients with TBI undergoing primary DC can evaluate the prognosis accurately and enhance the early identification of high-risk patients.

Clinical Value of Bilateral Balanced Frontotemporoparietal Decompressive Craniectomy in Severe Diffuse Traumatic Brain Injury

OBJECTIVE

To explore the clinical value of bilateral balanced frontotemporoparietal decompressive craniectomy (bbDC) in severe diffuse traumatic brain injury by comparison to the unilateral frontotemporoparietal decompressive craniectomy (uDC).

MATERIALS AND METHODS

Twenty three patients with severe diffuse traumatic brain injury from April 2015 to December 2019 were selected, including 10 cases underwent bbDC (bilateral group) and 13 cases underwent uDC (unilateral group). Compared with the postsurgical intracranial pressure (ICP), cerebral perfusion pressure, cerebral blood flow volume, postsurgical imaging score, the occurrence of complications as well as the 6 month outcome (Glasgow Outcome Scale, GOS) of two groups.

RESULTS

1. The postsurgical ICP was lower in the bbDC group than in the uDC group, while the postsurgical CCP and cerebral blood flow volume were higher in the bbDC group than in the uDC group. 2. Postsurgical imaging scores of the bbDC group were lower, indicating that the decompression effect of bbDC was more exhaustive than that of the uDC group. 3. The incidence of intraoperative acute cerebral bulging was lower in bbDC group than in uDC group. 4. The bbDC could effectively reduce the proportion of patients with the worst prognosis (dead+vegetative state).

CONCLUSION

For patients with severe, diffuse traumatic brain injury combined with bilateral or unilateral pupil dilation, bilateral balanced decompression craniotomy is an effective method, which should be performed as soon as possible. As compared to unilateral decompression, the decompression effect on the brainstem is more thorough; the incidence of acute cerebral bulging, postoperative incisional hernia, and postoperative cerebral infarction involving a large area are reduced. ICP can be better controlled, cerebral perfusion pressure and cerebral blood flow increases, improving the patient's survival rate, quality of life, and prognosis.

Effect of tranexamic acid on the prognosis of patients with traumatic brain injury undergoing craniotomy: study protocol for a randomised controlled trial

INTRODUCTION

Abnormal coagulation function aggravates the prognosis of patients with traumatic brain injury (TBI). It was reported that the antifibrinolytic drug tranexamic acid (TXA) could reduce intracranial haemorrhage and mortality in non-operative patients with TBI. However, there is a lack of evaluation of TXA in patients with TBI undergoing craniotomy.

METHODS AND ANALYSIS

This is a single-centre randomised controlled, double-blind, parallel study aiming to investigate the effectiveness and safety of TXA in patients with TBI during the perioperative period. Blood loss and transfusion, neurological function, adverse events, mortality and serum immune-inflammatory cytokines will be collected and analysed.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Medical Ethics Committee of Beijing Tian Tan Hospital, Capital Medical University (reference number KY 2020-136-03). The results of this study will be disseminated through presentations at scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100041911.

Can Cranioplasty Be Considered a Tool to Improve Cognitive Recovery Following Traumatic Brain Injury? A 5-Years Retrospective Study

Cranioplasty (CP) is a neurosurgical intervention of skull repairing following a decompressive craniectomy. Unfortunately, the impact of cranioplasty on cognitive and motor function is still controversial. Fifteen TBI subjects aged 26–54 years with CP after decompressive craniectomy were selected in this observational retrospective study. As per routine clinical practice, a neuropsychological evaluation carried out immediately before the cranioplasty (Pre CP) and one month after the cranioplasty (T0) was used to measure changes due to CP surgery. This assessment was performed each year for 5 years after discharge in order to investigate long-term cognitive changes (T1-T5). Before cranioplasty, about 53.3% of subjects presented a mild to severe cognitive impairment and about 40.0% a normal cognition. After CP, we found a significant improvement in all neuropsychological test scores. The more significant differences in cognitive recovery were detected after four years from CP. Notably, we found significant differences between T4 and T0-T1, as well as between T5 and T0-T1-T2 in all battery tests. This retrospective study further suggests the importance of CP in the complex management of patients with TBI showing how these patients might improve their cognitive function over a long period after the surgical procedure.

Cranioplasty Following Severe Traumatic Brain Injury: Role in Neurorecovery

PURPOSE OF REVIEW

Decompressive craniectomy (DC) is a life-saving procedure performed in refractory intracranial pressure increase and mass lesion due to severe traumatic brain injury (TBI). Cranioplasty primarily intends to maintain cerebral protection and reconstruct aesthetic appearance. Also, cranioplasty can enable neurological rehabilitation and potentially augment neurological recovery. This article reviews recent studies on the effect of cranioplasty on neurological recovery in severe TBI.

RECENT FINDINGS

Recent findings suggested that cranioplasty has the potential to enhance neurological recovery after severe TBI. Cranioplasty may alleviate cognitive and functional deficits by reinstating the regular cerebrospinal fluid dynamics and improving brain perfusion. Analyses on the effects of cranioplasty timing on neurological recovery likely favor early cranioplasty. Also, materials used during cranioplasty, autologous and exogenous, were suggested to have similar effects in recovery. Although neurological therapy of TBI patients is still a serious challenge, recent findings represent the possible enhancing effect of cranioplasty on neurological recovery.

Radiographic predictors of clinical outcome in traumatic brain injury after decompressive craniectomy

BACKGROUND

Primary decompressive craniectomy (DC) is considered for traumatic brain injury (TBI) patients with clinical deterioration, presenting large amounts of high-density lesions on computed tomography (CT). Postoperative CT findings may be suitable for prognostic evaluation. This study evaluated the radiographic predictors of clinical outcome and survival using pre- and postoperative CT scans of such patients.

METHODS

We enrolled 150 patients with moderate to severe TBI who underwent primary DC. They were divided into two groups based on the 6-month postoperative Glasgow Outcome Scale Extended scores (1-4, unfavorable; 5-8, favorable). Radiographic parameters, including hemorrhage type, location, presence of skull fracture, midline shifting, hemispheric diameter, effacement of cisterns, parenchymal hypodensity, and craniectomy size, were reviewed. Stepwise logistic regression analysis was used to identify the prognostic factors of clinical outcome and 6-month mortality.

RESULTS

Multivariable logistic regression analysis revealed that age (odds ratio [OR] = 1.09; 95% confidence interval [CI] 1.032-1.151; p = 0.002), postoperative low density (OR = 12.58; 95% CI 1.247-126.829; p = 0.032), and postoperative effacement of the ambient cistern (OR = 14.52; 95% CI 2.234-94.351; p = 0.005) and the crural cistern (OR = 4.90; 95% CI 1.359-17.678; p = 0.015) were associated with unfavorable outcomes. Postoperative effacement of the crural cistern was the strongest predictor of 6-month mortality (OR = 8.93; 95% CI 2.747-29.054; p = 0.000).

CONCLUSIONS

Hemispheric hypodensity and effacement of the crural and ambient cisterns on postoperative CT after primary DC seems to associate with poor outcome in patients with TBI.

Security and reliability of CUSTOMBONE cranioplasties: A prospective multicentric study

BACKGROUND

Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis.

OBJECTIVE

To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years.

RESULTS

Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection.

CONCLUSION

Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary.

Transport Time and Mortality in Critically Ill Patients with Severe Traumatic Brain Injury

PURPOSE

Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes.

METHODS

Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer.

RESULTS

Patients had a median age of 43 years (interquartile range [IQR] 26-59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26-43). Median transportation time was 80 minutes (IQR 40-315). ICU and hospital length of stay were 6 days (IQR 2-12) and 20 days (IQR 7-42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95-1.01). There was also no significant effect on discharge disposition.

CONCLUSIONS

No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.

Decompressive Craniectomy Improves QTc Interval in Traumatic Brain Injury Patients

Background: Traumatic brain injury (TBI) is commonly associated with cardiac dysfunction, which may be reflected by abnormal electrocardiograms (ECG) and/or contractility. TBI-related cardiac disorders depend on the type of cerebral injury, the region of brain damage and the severity of the intracranial hypertension. Decompressive craniectomy (DC) is commonly used to reduce intra-cranial hypertension (ICH). Although DC decreases ICH rapidly, its effect on ECG has not been systematically studied. The aim of this study was to analyze the changes in ECG in patients undergoing DC. Methods: Adult patients without previously known cardiac diseases treated for isolated TBI with DC were studied. ECG variables, such as: spatial QRS-T angle (spQRS-T), corrected QT interval (QTc), QRS and T axes (QRS_ax and T_ax, respectively), STJ segment and the index of cardio-electrophysiological balance (iCEB) were analyzed before DC and at 12–24 h after DC. Changes in ECG were analyzed according to the occurrence of cardiac arrhythmias and 28-day mortality. Results: 48 patients (17 female and 31 male) aged 18–64 were studied. Intra-cranial pressure correlated with QTc before DC (p < 0.01, r = 0.49). DC reduced spQRS-T (p < 0.001) and QTc interval (p < 0.01), increased Tax (p < 0.01) and changed STJ in a majority of leads but did not affect QRS_ax and iCEB. The iCEB was relatively increased before DC in patients who eventually experienced cardiac arrhythmias after DC (p < 0.05). Higher post-DC iCEB was also noted in non-survivors (p < 0.05), although iCEB values were notably heart rate-dependent. Conclusions: ICP positively correlates with QTc interval in patients with isolated TBI, and DC for relief of ICH reduces QTc and spQRS-T. However, DC might also increase risk for life-threatening cardiac arrhythmias, especially in ICH patients with notably prolonged QTc before and increased iCEB after DC.

Outcomes of patients undergoing craniotomy and decompressive craniectomy for severe traumatic brain injury with brain herniation: A retrospective study

The treatment of severe traumatic brain injury (TBI) with brain herniation is challenging because outcomes are often associated with high mortality and morbidity. Our aim was to identity factors contributing to decompressive craniectomy (DC) and evaluate treatment outcomes in patients with severe TBI with brain herniation.In this retrospective study, we analyzed medical records of severe TBI with brain herniation from May 2009 to December 2013. We reviewed their demographic data, mechanism of injury, Glasgow Coma Scale (GCS) score, pupil status, computed tomography findings, surgical treatment methods, time interval between brain herniation and surgery, as well as outcomes. GCS and pupil status are clinical parameters for detecting increase intracranial pressure while brain parenchyma bulged above the inner plate of the skull during operation indicated brain swelling as well as increased intracranial pressure on which basis the decision to perform DC or craniotomy was determined intraoperatively.One hundred ninety-four patients were included in the study. We performed DC in 143 of the patients while 51 of them we performed craniotomy. There were no statistically significant differences in the age, gender, or injury mechanism between the 2 groups. GCS, pupillary dilation, midline shift, hematoma type and timing of surgery were associated with DC. Nevertheless, logistic regression analysis revealed that hematoma type and timing of surgery were significantly associated with favorable DC outcomes (P < .001 and P = .023). Subdural hematoma and timing of surgery >1 hour were both identified as risk factors for DC. Six months after TBI, 34.0% of patients exhibited favorable outcomes. Overall mortality rate was 30.4%. Age, GCS, pupil dilation, hematoma type, and timing of surgery were all associated with patient outcomes. Further logistic regression analysis revealed that, lower GCS, bilateral pupil dilation, timing of surgery >1 hour, and advanced age were independent risk factors for poor outcomes (P = .001, P = .037, P = .028, and P = .001, respectively).Our study revealed that, DC is not mandatory for all TBI patients with brain herniation. Nevertheless, DC decreases mortality rate in severe TBI patients with brain herniation. Subdural hematoma and timing of surgery >1 hour are key indicators for DC. Lower GCS, bilateral pupil dilation, delayed timing of surgery and advance age are indicators of poor outcomes.

Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature

Compartment syndrome can occur in many body regions and may range from homeostasis asymptomatic alterations to severe, life-threatening conditions. Surgical intervention to decompress affected organs or area of the body is often the only effective treatment, although evidences to assess the best timing of intervention are lacking. Present paper systematically reviewed the literature stratifying timings according to the compartmental syndromes which may beneficiate from immediate, early, delayed, or prophylactic surgical decompression. Timing of decompression have been stratified into four categories: (1) immediate decompression for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, (2) early decompression with the time burden of 3-12 h and in any case before clinical signs of irreversible deterioration, (3) delayed decompression identified with decompression performed after 12 h or after signs of clinical deterioration has occurred, and (4) prophylactic decompression in those situations where high incidence of compartment syndrome is expected after a specific causative event.

Decompressive Craniectomy in Traumatic Brain Injury: An Institutional Experience of 131 Cases in Two Years

Decompressive craniectomy (DC) effectively reduces intracranial pressure (ICP), but is not considered to be a first-line procedure. We retrospectively analyzed sociodemographic, clinical, and surgical characteristics associated with the prognosis of patients who underwent DC to treat traumatic intracranial hypertension (ICH) at the Restauração Hospital (HR) in Recife, Brazil between 2015 and 2016, and compared the clinical features with surgical timing and functional outcome at discharge. The data were collected from 131 medical records in the hospital database. A significant majority of the patients were young adults (age 18-39 years old; 75/131; 57.3%) and male (118/131; 90.1%). Road traffic accidents, particularly those involving motorcycles (57/131; 44.5%), were the main cause of the traumatic event. At initial evaluation, 63 patients (48.8%) were classified with severe traumatic brain injury (TBI). Pupil examination showed no abnormalities for 91 patients (71.1%), and acute subdural hematoma was the most frequently observed lesion (83/212; 40%). Glasgow Outcome Scale (GOS) score was used to categorize surgical results and 51 patients (38.9%) had an unfavorable outcome. Only the Glasgow Coma Scale (GCS) score on admission (score of 3-8) was more likely to be associated with unfavorable outcome (p-value = 0.009), indicating that this variable may be a determinant of mortality and prognostic of poor outcome. Patients who underwent an operation sooner after injury, despite having a worse condition on admission, presented with clinical results that were similar to those of patients who underwent surgery 12 h after hospital admission. These results emphasize the importance of early DC for management of severe TBI. This study shows that DC is a common procedure used to manage TBI patients at HR.

Low-Value Clinical Practices in Adult Traumatic Brain Injury: An Umbrella Review

Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last 3 decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (Assessing the Methodological Quality of Systematic Reviews), reported effect sizes, and credibility of evidence (I to IV). The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: computed tomography (CT) in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality, and most included studies had a high risk of bias.

Effects of seawater immersion on open traumatic brain injury in rabbit model

We emulated instances of open traumatic brain injuries (TBI) in a maritime disaster. New Zealand rabbit animal models were used to evaluate the pathophysiological changes in open TBI with and without the influence of artificial seawater. New Zealand rabbits were randomly divided into 3 groups. Control group consisted of only normal animals. Animals in TBI and TBI + Seawater groups underwent craniotomy with dura mater incised and brain tissue exposed to free-fall impact. Afterward, only TBI + Seawater group received on-site artificial seawater infusion. Brain water content (BWC) and permeability of blood-brain barrier (BBB) were assessed. Reactive oxygen species levels were measured. Western blotting and immunofluorescence were employed to detect: apoptosis-related factors Caspase-3, Bax and Bcl-2; angiogenesis-related factors CD31 and CD34; astrogliosis-related factor glial fibrillary acidic protein (GFAP); potential neuron injury indicator neuron-specific enolase (NSE). Hematoxylin & eosin, Masson-trichrome and Nissl stainings were performed for pathological observations. Comparing to Control group, TBI group manifested abnormal neuronal morphology; increased BWC; compromised BBB integrity; increased ROS, Bax, CD31, CD34, Caspase-3 and GFAP expressions; decreased Bcl-2 and NSE expression. Seawater immersion caused all changes, except BWC, to become more significant. Seawater immersion worsens the damage inflicted to brain tissue by open TBI. It aggravates hypoxia in brain tissue, upregulates ROS expression, increases neuron sensitivity to apoptosis-inducing factors, and promotes angiogenesis as well as astrogliosis.

Concurrent Versus Staged Procedures for Ventriculoperitoneal Shunt and Cranioplasty: A 10-Year Retrospective Comparative Analysis of Surgical Outcomes

BACKGROUND

Many patients undergoing decompressive craniectomy will develop persistent hydrocephalus before cranioplasty. Therefore, surgeons must decide whether to perform ventriculoperitoneal shunt (VPS) placement and cranioplasty simultaneously or in staged procedures. With limited, conflicting data reported, this decision has often been made by personal preference. The objective of the present study was to compare the surgical outcomes between patients undergoing concurrent or staged VPS placement and cranioplasty.

METHODS

We performed a 10-year retrospective comparative analysis of patients who had undergone either simultaneous or staged VPS placement and cranioplasty at a tertiary academic medical center.

RESULTS

Of the 40 patients, 18 had undergone concurrent procedures and 22 had undergone VPS placement before a separate cranioplasty procedure. The concurrent group was significantly older, had more often had the VPS placed in the external ventricular drain site, and had had more patients taking aspirin at surgery. The rates of infection, resorption, and reoperation did not differ significantly, although reoperation showed a trend toward occurring less frequently in the concurrent group. Hospital-acquired infection occurred significantly less frequently in the concurrent patients. The rate of VPS-associated outcomes did not differ significantly between the 2 groups.

CONCLUSIONS

Because of the trend toward a reduced reoperation rate, the significantly reduced rate of hospital-acquired infection, and the reduction in the number of surgeries, we recommend that patients awaiting cranioplasty in the setting of persistent hydrocephalus undergo concurrent VPS placement and cranioplasty rather than staged procedures.

Decompressive Craniectomy Is Associated With Good Quality of Life Up to 10 Years After Rehabilitation From Traumatic Brain Injury

OBJECTIVES

Traumatic brain injury is the number one cause of death in children and young adults and has become increasingly prevalent in the elderly. Decompressive craniectomy prevents intracranial hypertension but does not clearly improve physical outcome 6 months after traumatic brain injury. However, it has not been analyzed if decompressive craniectomy affects traumatic brain injury patients' quality of life in the long term.

DESIGN

Therefore, we conducted a cross-sectional study assessing health-related quality of life in traumatic brain injury patients with or without decompressive craniectomy up to 10 years after injury.

SETTING

Former critical care patients.

PATIENTS

Chronic traumatic brain injury patients having not (n = 37) or having received (n = 98) decompressive craniectomy during the acute treatment.

MEASUREMENTS AND MAIN RESULTS

Decompressive craniectomy was necessary in all initial traumatic brain injury severity groups. Eight percent more decompressive craniectomy patients reported good health-related quality of life with a Quality of Life after Brain Injury total score greater than or equal to 60 compared with the no decompressive craniectomy patients up to 10 years after traumatic brain injury (p = 0.004). Initially, mild classified traumatic brain injury patients had a median Quality of Life after Brain Injury total score of 83 (decompressive craniectomy) versus 62 (no decompressive craniectomy) (p = 0.028). Health-related quality of life regarding physical status was better in decompressive craniectomy patients (p = 0.025). Decompressive craniectomy showed a trend toward better health-related quality of life in the 61-85-year-old reflected by median Quality of Life after Brain Injury total scores of 62 (no decompressive craniectomy) versus 79 (decompressive craniectomy) (p = 0.06).

CONCLUSIONS

Our results suggest that decompressive craniectomy is associated with good health-related quality of life up to 10 years after traumatic brain injury. Thus, decompressive craniectomy may have an underestimated therapeutic potential after traumatic brain injury.

Early cranioplasty associated with a lower rate of post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury

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.

Early Decompressive Craniectomy as Management for Severe Traumatic Brain Injury in the Pediatric Population: A Comprehensive Literature Review

BACKGROUND

Severe traumatic brain injuries (TBIs) are a principal cause of neurologic dysfunction and death in the pediatric population. After medical management, the second-tier treatment is decompressive craniectomy in cases of intractable intracranial pressure (ICP) elevation. This literature review offers evidence of early (within 24 hours) and ultraearly (6-12 hours) decompressive craniectomy as an effective form of management for severe TBI in the pediatric population.

METHODS

We conducted a literature review of articles published from 1996 to 2019 to elucidate neurologic outcomes after early decompressive craniectomy in pediatric patients who suffered a severe TBI. Time to decompressive craniectomy and neurologic outcomes were recorded and reported descriptively. Qualitative data describe clinically important correlations between pre- and postoperative ICP levels and improved postoperative neurologic outcomes.

RESULTS

Seventy-eight patients were included in this study. The median age of patients at diagnosis was 10 years of age (range, 1 months to 19 years). Median admission Glasgow Coma Scale score was 5 (range, 3-8). Time to decompressive craniectomy ranged from 1 to 24 hours. Median peak preoperative ICP was 40 (range, 3-90; n = 49). Median postoperative ICP was 20 (range, 0-80; n = 33). Median Glasgow Outcome Scale (GOS) score at discharge was 2 (range, 1-5; n = 11). Median GOS score at 3- and 6-month follow-up was 3 (range, 1-5; n = 11). Median GOS score at 7- to 23-month follow-up was 4 (range, 1-5; n = 29). Median GOS score at 24- to 83-month follow-up was 4 (range, 1-5; n = 31). Median modified Rankin Scale score at discharge was 3 (range, 2-4; n = 6). Median modified Rankin Scale score at 6- to 48-month follow-up was 2 (range, 0-3; n = 6). Median Rancho Los Amigos Scale (RLAS) score at discharge was 6 (range, 4-8; n = 5). Median RLAS score at 6-month follow-up was 10 (range, 8-10; n = 5).

CONCLUSIONS

Early (within 24 hours), with consideration of ultraearly (within 6-12 hours), decompressive craniectomy for severe TBI should be offered to pediatric patients in settings with refractory ICP elevation. Reduction of ICP allows for prompt disruption of pathophysiologic cascades and improved neurologic outcomes.

Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury

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.

Association of time to craniectomy with survival in patients with severe combat-related brain injury

OBJECTIVEIn combat and austere environments, evacuation to a location with neurosurgery capability is challenging. A planning target in terms of time to neurosurgery is paramount to inform prepositioning of neurosurgical and transport resources to support a population at risk. This study sought to examine the association of wait time to craniectomy with mortality in patients with severe combat-related brain injury who received decompressive craniectomy.METHODSPatients with combat-related brain injury sustained between 2005 and 2015 who underwent craniectomy at deployed surgical facilities were identified from the Department of Defense Trauma Registry and Joint Trauma System Role 2 Registry. Eligible patients survived transport to a hospital capable of diagnosing the need for craniectomy and performing surgery. Statistical analyses included unadjusted comparisons of postoperative mortality by elapsed time from injury to start of craniectomy, and Cox proportional hazards modeling adjusting for potential confounders. Time from injury to craniectomy was divided into quintiles, and explored in Cox models as a binary variable comparing early versus delayed craniectomy with cutoffs determined by the maximum value of each quintile (quintile 1 vs 2-5, quintiles 1-2 vs 3-5, etc.). Covariates included location of the facility at which the craniectomy was performed (limited-resource role 2 facility vs neurosurgically capable role 3 facility), use of head CT scan, US military status, age, head Abbreviated Injury Scale score, Injury Severity Score, and injury year. To reduce immortal time bias, time from injury to hospital arrival was included as a covariate, entry into the survival analysis cohort was defined as hospital arrival time, and early versus delayed craniectomy was modeled as a time-dependent covariate. Follow-up for survival ended at death, hospital discharge, or hospital day 16, whichever occurred first.RESULTSOf 486 patients identified as having undergone craniectomy, 213 (44%) had complete date/time values. Unadjusted postoperative mortality was 23% for quintile 1 (n = 43, time from injury to start of craniectomy 30-152 minutes); 7% for quintile 2 (n = 42, 154-210 minutes); 7% for quintile 3 (n = 43, 212-320 minutes); 19% for quintile 4 (n = 42, 325-639 minutes); and 14% for quintile 5 (n = 43, 665-3885 minutes). In Cox models adjusted for potential confounders and immortal time bias, postoperative mortality was significantly lower when time to craniectomy was within 5.33 hours of injury (quintiles 1-3) relative to longer delays (quintiles 4-5), with an adjusted hazard ratio of 0.28, 95% CI 0.10-0.76 (p = 0.012).CONCLUSIONSPostoperative mortality was significantly lower when craniectomy was initiated within 5.33 hours of injury. Further research to optimize craniectomy timing and mitigate delays is needed. Functional outcomes should also be evaluated.

The Role of Decompressive Craniectomy in the Context of Severe Traumatic Brain Injury: Summary of Results and Analysis of the Confidence Level of Conclusions From Systematic Reviews and Meta-Analyses

Introduction: Traumatic brain injury (TBI) is a global epidemic. The incidence of TBI in low and middle-income countries (LMICs) is three times greater than in high-income countries (HICs). Decompressive craniectomy (DC) is a surgical procedure to reduce intracranial pressure (ICP) and prevent secondary injury. Multiple comparative studies, and several randomized controlled trials (RCTs) have been conducted to investigate the influence of DC for patients with severe TBI on outcomes such as mortality, ICP, neurological outcomes, and intensive care unit (ICU) and hospital length of stay. The results of these studies are inconsistent. Systematic reviews and meta-analyses have been conducted in an effort to aggregate the data from the individual studies, and perhaps derive reliable conclusions. The purpose of this project was to conduct a review of the reviews about the effectiveness of DC to improve outcomes.

Methods: We conducted a systematic search of the literature to identify reviews and meta-analyses that met our pre-determined criteria. We used the AMSTAR 2 instrument to assess the quality of each of the included reviews, and determine the level of confidence.

Results: Of 973 citations from the original search, five publications were included in our review. Four of them included meta-analyses. For mortality, three reviews found a positive effect of DC compared to medical management and two found no significant difference between groups. The four reviews that measured neurological outcome found no benefit of DC. The two reviews that assessed ICP both found DC to be beneficial in reducing ICP. DC demonstrated a significant reduction in ICU length of stay in the one study that measured it, and a significant reduction in hospital length of stay in the two studies that measured it. According to the AMSTAR 2 criteria, the five reviews ranged in levels of confidence from low to critically low.

Conclusion: Systematic reviews and meta-analyses are important approaches for aggregating information from multiple studies. Clinicians rely of these methods for concise interpretation of scientific literature. Standards for quality of systematic reviews and meta-analyses have been established to support the quality of the reviews being produced. In the case of DC, more attention must be paid to quality standards, in the generation of both individual studies and reviews.

Using computerized tomography perfusion to measure cerebral hemodynamics following treatment of traumatic brain injury in rabbits

The present study aimed to investigate the use of computerized tomography (CT) perfusion for evaluating cerebral hemodynamics following traumatic brain injury (TBI) in rabbits. The animals were randomly assigned into four groups (n=10 animals/group): i) Control, ii) TBI, iii) TBI + common decompression and iv) TBI + controlled decompression groups. A TBI model was established in rabbits using epidural balloon inflation. In the groups receiving intervention, animals were provided common decompression or controlled decompression treatments. Conventional CT and CT perfusion scanning were performed, with cerebral hemodynamic indices, including regional cerebral blood flow (rCBF), regional cerebral blood volume (rCBV) and mean transit time (MTT) being measured. Blood-brain barrier (BBB) permeability was evaluated using Evans blue staining. Compared with those in the control group, rCBF and rCBV values of the bilateral temporal lobes and basal ganglion in the TBI, TBI + common decompression and TBI + controlled decompression groups were significantly lower, whereas the MTT values were markedly prolonged and Evans blue dye content was greatly increased (P<0.01). Controlled decompression was demonstrated to be more potent than common decompression for preventing TBI-induced decline in rCBF and rCBV values in the bilateral temporal lobes and basal ganglion, as well as reversing TBI-induced extension of MTT in the bilateral temporal lobes (P<0.01 vs. TBI group). However, neither common nor controlled decompression could reduce TBI-induced increase in BBB permeability. In conclusion, these findings indicate that CT perfusion may be used to monitor cerebral hemodynamics following TBI in rabbits. Controlled decompression was deduced to be more potent than common decompression for preventing abnormalities in cerebral hemodynamics after TBI.

Cosmetic Outcome of Cranioplasty After Decompressive Craniectomy-An Overlooked Aspect

BACKGROUND

Cranioplasty (CP) is an obligatory surgery after decompressive craniectomy (DC). The primary objective is to protect the brain from external injury and prevent syndrome of trephined. In a government hospital, such cases pose a significant burden to a trauma center. Because of this reason, cosmetic outcome is never taken into account for the CP. We present results of CP performed at our hospital.

METHODS

This is a retrospective review of the cases of CP performed over the past 3 years at our hospital. The cosmetic outcome was divided into 3 grades: 1-good symmetrical, 2-irregularities, 2a-elevated and 2b depressed, and 3-bad cosmetic outcome requiring reoperation.

RESULTS

A total of 133 patients with acute brain injury underwent CP during the study period. The outcome was good in 74 (55.6%) and bad, requiring reoperation, in 2 (1.5%) cases. Various types of the CP materials like autologous bone flap, titanium mesh, and customized titanium plates were used. Methods of fixation were threads or miniplates and screws. In univariate analysis, cerebral venous thrombosis as an indication for DC, use of autologous bone flap, and fixation with thread were associated with poor outcome. However, in multivariate analysis only the method of implant fixation was associated with poor outcome. It was found that if screws and plates are used for fixation of bone flap, the chances of bad outcome are reduced by 74.6%.

CONCLUSIONS

The cosmetic outcome is overlooked for CP. The bone flap fixation has to be rigid for a good outcome.

Mortality After Traumatic Brain Injury in Elderly Patients: A New Scoring System

BACKGROUND

Traumatic brain injury (TBI) remains a life-threatening condition characterized by growing incidence worldwide, particularly in the aging population, in which the primary goal of treatment appears to be avoidance of chronic institutionalization.

METHODS

To identify independent predictors of 30-day mortality or vegetative state in a geriatric population and calculate an intuitive scoring system, we screened 480 patients after TBI treated at a single department of neurosurgery over a 2-year period. We analyzed data of 214 consecutive patients aged ≥65 years, including demographics, medical history, cause and time of injury, neurologic state, radiologic reports, and laboratory results. A predictive model was developed using logistic regression modeling with a backward stepwise feature selection.

RESULTS

The median Glasgow Coma Scale (GCS) score on admission was 14 (interquartile range, 12-15), whereas the 30-day mortality or vegetative state rate amounted to 23.4%. Starting with 20 predefined features, the final prediction model highlighted the importance of GCS motor score (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.09-0.32); presence of comorbid cardiac, pulmonary, or renal dysfunction or malignancy (OR, 2.86; 9 5% CI, 1.08-7.61); platelets ≤100 × 10⁹ cells/L (OR, 13.60; 95% CI, 3.33-55.49); and red blood cell distribution width coefficient of variation ≥14.5% (OR, 2.91; 95% CI, 1.09-7.78). The discovered coefficients were used for nomogram development. It was further simplified to facilitate clinical use. The proposed scoring system, Elderly Traumatic Brain Injury Score (eTBI Score), yielded similar performance metrics.

CONCLUSIONS

The eTBI Score is the first scoring system designed specifically for older adults. It could constitute a framework for clinical decision-making and serve as an outcome predictor. Its capability to stratify risk provides reliable criteria for assessing efficacy of TBI management.

Prognostic Predictors of Early Outcomes and Discharge Status of Patients Undergoing Decompressive Craniectomy After Severe Traumatic Brain Injury

OBJECTIVE

Although several prognostic factors for traumatic brain injury (TBI) have been evaluated, a useful predictive scoring model for the outcomes has not been developed for patients with severe TBI who undergo decompressive craniectomy (DC). The aim of the present study was to determine independent predictors and develop a multivariate logistic regression equation to predict the early outcome and discharge status for patients with severe TBI who have undergone DC.

METHODS

A total of 13 different variables were evaluated. The data from all 278 patients with severe TBI who had undergone DC in the present study were retrospectively evaluated from July 2011 to June 2017. Using univariate, multiple logistic regression and prognostic regression scoring equations it was possible to draw receiver operating characteristic curves to predict the early outcomes and discharge status after TBI.

RESULTS

We found that younger age (P = 0.012), no significant medical history (P = 0.044), diameter of both pupils <4 mm (P = 0.032), higher admission Glasgow coma scale score (P = 0.004), no tracheotomy (P < 0.001), and DC for severe TBI were associated with a favorable early outcome and discharge status. Using receiver operating characteristic curves to predict the probability of a favorable outcome, the sensitivity was 80.0% and the specificity was 79.5%.

CONCLUSIONS

Our preliminary findings have shown that 5 variables can be used as independent predictors in assessing the early outcome and discharge status for patients with severe TBI after DC.

Is traumatic brain injury a risk factor for neurodegeneration? A meta-analysis of population-based studies

Background

To determine the association of prior traumatic brain injury (TBI) with subsequent diagnosis of neurodegeneration disease.

Methods

All studies from 1980 to 2016 reporting TBI as a risk factor for diagnoses of interest were identified by searching PubMed, Embase, study references, and review articles. The data and study design were assessed by 2 investigators independently. A meta-analysis was performed by RevMan 5.3.

Results

There were 18 studies comprising 3,263,207 patients. Meta-analysis revealed a significant association of prior TBI with subsequent dementia. The pooled odds ratio (OR) for TBI on development of dementia, FTD and TDP-43 associated disease were 1.93 (95% CI 1.47–2.55, p < 0.001), 4.44 (95% CI 3.86–5.10, p < 0.001), and 2.97 (95% CI 1.35–6.53, p < 0.001). However, analyses of individual diagnoses found no evidence that the risk of Alzheimer’s disease, and Parkinson’s disease in individuals with previous TBI compared to those without TBI.

Conclusions

History of TBI is not associated with the development of subsequent neurodegeneration disease. Care must be taken in extrapolating from these results because no suitable criteria define post TBI neurodegenerative processes. Therefore, further research in this area is needed to confirm these questions and uncover the link between TBI and neurodegeneration disease.

Seizure After Cranioplasty: Incidence and Risk Factors

BACKGROUND

To investigate clinical characteristics of postcranioplasty seizures (PCS) first observed after cranioplasty after decompressive craniectomy (DC) to treat traumatic brain injury and to define factors that increase PCS risk.

METHODS

This retrospective study, covering the period between January 2008 and July 2015, compared PCS in postcranioplasty patients. Postcranioplasty seizures risk factors included diabetes mellitus, hypertension, time between DC and cranioplasty, duraplasty material, cranioplasty contusion location, electrocautery method, PCS type, and infection. Multivariate logistic regression analysis was performed and confidence intervals (CIs) were calculated (95% CI).

RESULTS

Of 270 patients, 32 exhibited initial PCS onset postcranioplasty with 11.9% incidence (32/270). Patients fell into immediate (within 24 hours), early (from 1 to 7 days), and late (after 7 days) PCS groups with frequencies of 12, 5, and 15 patients, respectively. Generalized, partial, and mixed seizure types were observed in 13, 13, and 6 patients, respectively. Multivariate logistic regression analysis showed increased risk with increasing age (>50 years). Cranioplasty contusion location, precranioplasty deficits, duraplasty material, and monopolar electrocautery were predictive of PCS onset (P < 0.05). Increased DC to cranioplasty interval increased risk but was not statistically significant (P = 0.062).

CONCLUSIONS

Understanding risk factors for PCS will benefit the management of cranioplasty patients.

Cisternostomy for Refractory Posttraumatic Intracranial Hypertension

BACKGROUND

The current surgical treatment of choice for refractory intracranial hypertension after traumatic brain injury (TBI) is decompressive craniectomy. Despite efficacy in control of intracranial pressure (ICP), its contribution to an improved outcome is debatable.

CASE DESCRIPTION

We describe a case of refractory intracranial hypertension successfully managed with cisternostomy. The rationale for this surgical technique is discussed, with a focus on the pathophysiologic processes underlying elevated ICP and its improvement after surgery.

CONCLUSION

Cisternostomy proved to have an immediate effect in controlling ICP and improving brain oxygenation and metabolism.

Osteoblast and Bacterial Culture from Cryopreserved Skull Flap after Craniectomy: Laboratory Study

Objective

Cranioplasty using a cryopreserved skull flap is a wide spread practice. The most well-known complications of cranioplasty are postoperative surgical infections and bone flap resorption. In order to find biological evidence of cryopreserved cranioplasty, we investigated microorganism contamination of cryopreserved skulls and cultured osteoblasts from cryopreserved skulls.

Methods

Cryopreserved skull flaps of expired patients stored in a bone bank were used. Cryopreserved skulls were packaged in a plastic bag and wrapped with cotton cloth twice. After being crushed by a hammer, cancellous bone between the inner and outer table was obtained. The cancellous bone chips were thawed in a water bath of 30°C rapidly. After this, osteoblast culture and general microorganism culture were executed. Osteoblast cultures were done for 3 weeks. Microorganism cultures were done for 72 hours.

Results

A total of 47 cryopreserved skull flaps obtained from craniectomy was enrolled. Of the sample, 11 people were women, and the average age of patients was 55.8 years. Twenty four people had traumatic brain injuries, and 23 people had vascular diseases. Among the patients with traumatic brain injuries, two had fracture compound comminuted depressed. The duration of cryopreservation was, on average, 83.2 months (9 to 161 months). No cultured osteoblast was observed. No microorganisms were cultured.

Conclusion

In this study, neither microorganisms nor osteoblasts were cultured. The biological validity of cryopreserved skulls cranioplasty was considered low. However, the usage of cryopreserved skulls for cranioplasty is worthy of further investigation in the aspect of cost-effectiveness and risk-benefit of post-cranioplasty infection.

Formulation of a Three-Tier Cisternal Grade as a Predictor of In-Hospital Outcome from a Prospective Study of Patients with Traumatic Intracranial Hematoma

OBJECTIVE

Outcome prediction is of paramount importance in traumatic brain injury. Our objective of conducting this prospective study was to identify the predictors needed to formulate a prognostic score.

METHODS

Clinical and radiologic characteristics of 100 patients with traumatic intracranial hematoma were analyzed. Key measurements were taken in the midbrain and pontine regions and the status of each of the 9 basal cisterns was noted, by giving a score of 1 if they were visible and 0 if not. All the predictors were analyzed for outcome.

RESULTS

Total cisternal score was found to be an independent predictor of outcome. A grade was formulated by dividing the score into 3 levels.

CONCLUSIONS

The model based on cisternal status described in the study is technically simple and conveys the information regarding the outcome to the treating neurosurgeon. Because the score obtained seems to have low interobserver variation, we believe that it can be a useful tool not only in recording data in case files and interphysician communication but also in research into traumatic brain injury.