Decompressive Craniectomy for Traumatic Brain Injury: In-hospital Mortality-Associated Factors

Current trends and challenges: The landscape of perioperative mortality in intracranial surgeries in low- and middle-income settings: A narrative review

Background and Aims

Intracranial surgeries are pivotal in treating cerebral pathologies, particularly in resource-limited contexts, utilizing techniques such as craniotomy, transsphenoidal approaches, and endoscopy. However, challenges in low and middle income countries (LMICs), including resource scarcity, diagnostic delays, and a lack of skilled neurosurgeons, lead to elevated perioperative mortality (POM). This review seeks to identify major contributors to these challenges and recommend solutions for improved patient outcomes in neurosurgical care within LMICs.

Methods

This review examines POM in LMICs using a detailed literature search, focusing on studies from these regions. Databases like PubMed, EMBASE, and Google Scholar were utilized using specific terms related to "intracranial surgery," "perioperative mortality," "traumatic brain injuries," and "LMICs." Inclusion criteria covered various study designs and both pediatric and adult populations while excluding stand-alone abstracts and case reports.

Results

POM rates for intracranial surgeries differ widely across many low and middle-income regions: Africa sees rates from 2.5% to 39.1%, Asia between 3.6% and 34.8%, and Latin America and the Caribbean have figures ranging from 1.3% to 12%. The POM rates in LMICs were relatively higher compared to most first-world countries. The high POM rates in LMICs can be attributed to considerable delays and compromises in neurosurgical care delivery, exacerbated by late diagnoses and presentations of neurosurgical pathologies. This, coupled with limited resources, underdeveloped infrastructure, and training gaps, complicates intracranial disease management, leading to elevated POM.

Conclusion

Intracranial POM is a pronounced disparity within the neurosurgical field in LMICs. To mitigate intracranial POM, it is imperative to bolster healthcare infrastructure, amplify personnel training, foster global partnerships, and harness technologies like telemedicine. Tackling socioeconomic obstacles and prioritizing early detection through sustained funding and policy shifts can substantially enhance patient outcomes.

Decompressive Craniectomy in Severe Traumatic Brain Injury: The Intensivist's Point of View

INTRODUCTION

Traumatic brain injury (TBI) represents a severe pathology with important social and economic concerns, decompressive craniectomy (DC) represents a life-saving surgical option to treat elevated intracranial hypertension (ICP). The rationale underlying DC is to remove part of the cranial bones and open the dura mater to create space, avoiding secondary parenchymal damage and brain herniations. The scope of this narrative review is to summarize the most relevant literature and to discuss main issues about indication, timing, surgical procedure, outcome, and complications in adult patients involved in severe traumatic brain injury, underwent to the DC. The literature research is made with Medical Subject Headings (MeSH) terms on PubMed/MEDLINE from 2003 to 2022 and we reviewed the most recent and relevant articles using the following keywords alone or matched with each other: decompressive craniectomy; traumatic brain injury; intracranial hypertension; acute subdural hematoma; cranioplasty; cerebral herniation, neuro-critical care, neuro-anesthesiology. The pathogenesis of TBI involves both primary injuries that correlate directly to the external impact of the brain and skull, and secondary injuries due to molecular, chemical, and inflammatory cascade inducing further cerebral damage. The DC can be classified into primary, defined as bone flap removing without its replacement for the treatment of intracerebral mass, and secondary, which indicates for the treatment of elevated intracranial pressure (ICP), refractory to intensive medical management. Briefly, the increased brain compliance following bone removal reflects on CBF and autoregulation inducing an alteration in CSF dynamics and so, eventual complications. The risk of complications is estimated around 40%. The main cause of mortality in DC patients is due to brain swelling. In traumatic brain injury, primary or secondary decompressive craniectomy is a life-saving surgery, and the right indication should be mandatory in multidisciplinary medical-surgical consultation.

Clinical efficacy and prognosis of standard large trauma craniotomy for patients with severe frontotemporal craniocerebral injury

OBJECTIVE

To observe the clinical efficacy, incidence of postoperative complications, and the quality of life in patients with severe craniocerebral injury undergoing standard large trauma craniotomy.

METHODS

Seventy-eight patients with severe craniocerebral injury who had been admitted to Hubei Hanchuan People's Hospital were selected retrospectively and assigned into an observation group and control group according to the treatment received, with 39 patients in each group. Patients in the control group were treated with conventional decompressive craniotomy and those in the observation group with standard large trauma craniotomy. The prognosis (GOS score), intracranial pressure before and after surgery, neurological functions (NIHSS score), cerebral hemodynamics (Vm, Vs, PI), quality of life (SF-36 score) and postoperative complications were compared.

RESULTS

The number of patients whose GOS scores were graded 5 was markedly higher in the observation group than that in the control group (P<0.05). The postoperative intracranial pressure and NIHSS scores in the observation group were lower than those in the control group (P<0.001). The postoperative Vm, Vs and PI were lower in the observation group than those in the control group, respectively (P<0.001). There was no statistical difference in the incidence of complications in the two groups (P>0.05). The SF-36 scores in the observation group were higher than those of the control group (P<0.01).

CONCLUSION

Standard large trauma craniotomy is effective in treating patients with severe frontotemporal craniocerebral injury. It decreases intracranial pressure, improves neurological function and quality of life and results in a good prognosis.

Decompressive craniectomy can improve the recovery of neurological function, daily living ability and life quality of patients with intracerebral hemorrhage after surgery

OBJECTIVE

To determine the effect of decompressive craniectomy (DC) on the recovery of neurological function, daily living ability and life quality of patients with intracerebral hemorrhage (ICH) after surgery.

METHODS

Totally 290 patients with ICH admitted to our hospital from January 2018 to June 2020 were retrospectively enrolled and assigned to two groups according to different surgical methods. Among them, 138 patients who received craniotomy evacuation of hematoma (CEH) only were assigned to a control group (Con group), while the other 152 who received CEH combined with DC to a research group (Res group). The two groups were compared in the total effective rate, hematoma clearance rate, and complication rate. Additionally, the ICP and MMP-9 levels after surgery, National Institutes of Health Stroke Scale (NIHSS), activities of daily living (ADL), Fugl-Meyer Assessment of motor function (FMA), Glasgow outcome scale (GOS), Glasgow coma scale (GCS), and MOS 36-Item Short-Form Health Survey (SF-36) scores before and after surgery were also compared between the two groups.

RESULTS

After treatment, the Res group showed a notably higher total effective rate, hematoma clearance rate, and a notably lower complication rate than the Con group. On postoperative day 3 and 7, the Res group showed notably lower ICP than the Con group, and on postoperative day 7, the Res group showed a notably lower MMP-9 level as compared with the Con group. Additionally, 6 months after the surgery, the Res group got notably lower NIHSS scores and higher ADL, GOS, and SF-36 scores as compared with the Con group, and at 1 month after surgery, the Res group got notably higher FMA scores as compared to the Con group. Moreover, on postoperative day 7, the Res group got notably higher GCS scores than the Con group.

CONCLUSION

DC can improve the recovery of neurological function, daily living ability and life quality of patients with ICH after surgery.