1
|
Mutlucan UO, Orhun Ö, Özcan-Ekşi EE, Ekşi MŞ, Uçar T. Health-related quality of life measures in patients undergoing decompressive craniectomy for severe traumatic brain injury: a 6-year follow-up analysis. Int J Neurosci 2024:1-9. [PMID: 38446112 DOI: 10.1080/00207454.2024.2327400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 03/02/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE We aimed to assess the long-term neurological outcomes and the functionality and QoL in patients undergoing decompressive craniectomy for severe traumatic brain injury, respectively. MATERIALS AND METHODS Among the 120 patients who underwent decompressive craniectomy for severe TBI between 2002 and 2007, 101 were included based on the inclusion criteria. Long-term follow-up results (minimum 3 years) were available for 22 patients. The outcomes were assessed using the Glasgow Outcome Scale (GOS) and the functionality and HRQoL were assessed using the Short Form-36 (SF-36) (v2) and Quality of Life After Brain Injury (QoLIBRI) questionnaires. RESULTS Among the patients with severe TBI, 62 (61.4%) died and 39 (38.6%) were discharged to either home or a physical therapy facility. Eleven of the thirty-nine patients could not be reached and were excluded from the final analysis. The mean GOS of the remaining 28 patients was 4.14 ± 0.8 after 6.46 ± 1.64 years of follow-up. The HRQoL was assessed in 22 of the 28 patients. The HRQoL scores were lower in patients with TBI than in healthy controls. Furthermore, there was a significant difference in the HRQoL scores in patients with improved GOS scores than in those with unimproved GOS scores. CONCLUSIONS Health-related outcome scores could help clinicians understand the requirements of survivors of severe TBI to create a realistic rehabilitation target for them. QoLIBRI served as a good way of communication in these subjects.
Collapse
Affiliation(s)
- Umut Ogün Mutlucan
- Department of Neurosurgery, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ömer Orhun
- School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Emel Ece Özcan-Ekşi
- Physical Medicine and Rehabilitation Unit, Acıbadem Bağdat Caddesi Medical Center, Istanbul, Turkey
| | - Murat Şakir Ekşi
- Department of Neurosurgery, School of Medicine, Health Sciences University, Istanbul, Turkey
- FSM Training and Research Hospital, Neurosurgery Clinic, Istanbul, Turkey
| | - Tanju Uçar
- Department of Neurosurgery, Akdeniz University, School of Medicine, Antalya, Turkey
| |
Collapse
|
2
|
Abdulla E, Das K, Sridharan K, Waheed M, Abdulla F, Ravindra J, Luther H, Wireko AA. Prognostic variables predict clinical outcome after decompressive craniectomy: A single institute experience; A retrospective study. Medicine (Baltimore) 2024; 103:e36876. [PMID: 38181236 PMCID: PMC10766213 DOI: 10.1097/md.0000000000036876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/15/2023] [Indexed: 01/07/2024] Open
Abstract
Decompressive craniectomy (DC) is a well-established neurosurgical intervention in patients with high intracranial pressure who fail to respond to medical treatment. Data on predictive factors for functional outcomes in patients with DC who have malignant middle cerebral artery (MCA) infarction as opposed to intracranial hemorrhage (ICH) are scarce. Eighty-four patients who underwent DC treatment for ICH and malignant MCA infarction were examined. All patients underwent surgery in the Bahrain Salmaniya Medical Complex Neurosurgery Unit between January 2017 and June 2021. To determine whether any of these demonstrated a link to the functional outcome, radiographic factors were compared with clinical data. The postsurgical midline shift (MLS) (ICH group) showed the strongest correlation (ρ = 0.434; P = .006), as in the MCA infarction group as well (ρ = 0.46; P = .005). Further analyses using binary logistic regression with postsurgical basal cistern status and ∆ MLS, and it was observed to be statistically significant (odds ratios: 0.067, 95% CI: 0.007, 0.67; P = .021). The initial Glasgow coma scale, postsurgical MLS, basal cistern status, and ∆ are Measurable variables that can be used to predict outcomes in the groups with ICH and MCA infarction.
Collapse
Affiliation(s)
- Ebtesam Abdulla
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Krishna Das
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Kannan Sridharan
- Department of Pharmacology and Therapeutics, Arabian Gulf University, Manama, Bahrain
| | - Mohammed Waheed
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Fatima Abdulla
- Department of Neurology, Salmaniya Medical Complex, Manama, Bahrain
| | - Joseph Ravindra
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | - Harleen Luther
- Department of Neurosurgery, Salmaniya Medical Complex, Manama, Bahrain
| | | |
Collapse
|
3
|
Jeong TS, Choi DH, Kim WK. Comparison of Outcomes at Trauma Centers versus Non-Trauma Centers for Severe Traumatic Brain Injury. J Korean Neurosurg Soc 2023; 66:63-71. [PMID: 35996944 PMCID: PMC9837480 DOI: 10.3340/jkns.2022.0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/22/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Traumatic brain injury (TBI) is one of the most common injuries in patients with multiple trauma, and it associates with high post-traumatic mortality and morbidity. A trauma center was established to provide optimal treatment for patients with severe trauma. This study aimed to compare the treatment outcomes of patients with severe TBI between non-trauma and trauma centers based on data from the Korean Neuro-Trauma Data Bank System (KNTDBS). METHODS From January 2018 to June 2021, 1122 patients were enrolled in the KNTDBS study. Among them, 253 patients from non-traumatic centers and 253 from trauma centers were matched using propensity score analysis. We evaluated baseline characteristics, the time required from injury to hospital arrival, surgery-related factors, neuromonitoring, and outcomes. RESULTS The time from injury to hospital arrival was shorter in the non-trauma centers (110.2 vs. 176.1 minutes, p=0.012). The operation time was shorter in the trauma centers (156.7 vs. 128.1 minutes, p0.003). Neuromonitoring was performed in nine patients (3.6%) in the non-trauma centers and 67 patients (26.5%) in the trauma centers (p<0.001). Mortality rates were lower in trauma centers than in non-trauma centers (58.5% vs. 47.0%, p=0.014). The average Glasgow coma scale (GCS) at discharge was higher in the trauma centers (4.3 vs. 5.7, p=0.011). For the Glasgow outcome scale-extended (GOSE) at discharge, the favorable outcome (GOSE 5-8) was 17.4% in the non-trauma centers and 27.3% in the trauma centers (p=0.014). CONCLUSION This study showed lower mortality rates, higher GCS scores at discharge, and higher rates of favorable outcomes in trauma centers than in non-trauma centers. The regional trauma medical system seems to have a positive impact in treating patients with severe TBI.
Collapse
Affiliation(s)
- Tae Seok Jeong
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Dae Han Choi
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea,Address for correspondence : Dae Han Choi Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel : +82-32-460-3304, Fax : +82-32-460-3899, E-mail :
| | - Woo Kyung Kim
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - KNTDB Investigators
- Korea Neuro-Trauma Data Bank Committee, Korean Neurotraumatology Society, Korea
| |
Collapse
|
4
|
Liu Y, Liu X, Chen Z, Wang Y, Li J, Gong J, He A, Zhao M, Yang C, Yang W, Wang Z. Evaluation of decompressive craniectomy in mice after severe traumatic brain injury. Front Neurol 2022; 13:898813. [PMID: 35959411 PMCID: PMC9360741 DOI: 10.3389/fneur.2022.898813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/30/2022] [Indexed: 11/24/2022] Open
Abstract
Decompressive craniectomy (DC) is of great significance for relieving acute intracranial hypertension and saving lives after traumatic brain injury (TBI). In this study, a severe TBI mouse model was created using controlled cortical impact (CCI), and a surgical model of DC was established. Furthermore, a series of neurological function assessments were performed to better understand the pathophysiological changes after DC. In this study, mice were randomly allocated into three groups, namely, CCI group, CCI+DC group, and Sham group. The mice in the CCI and CCI+DC groups received CCI after opening a bone window, and after brain injury, immediately returned the bone window to simulate skull condition after a TBI. The CCI+DC group underwent DC and contused tissue removal 6 h after CCI. The mice in the CCI group underwent the same anesthesia process; however, no further treatment of the bone window and trauma was performed. The mice in the Sham group underwent anesthesia and the process of opening the skin and bone window, but not in the CCI group. Changes in Modified Neurological Severity Score, rotarod performance, Morris water maze, intracranial pressure (ICP), cerebral blood flow (CBF), brain edema, blood–brain barrier (BBB), inflammatory factors, neuronal apoptosis, and glial cell expression were evaluated. Compared with the CCI group, the CCI+DC group had significantly lower ICP, superior neurological and motor function at 24 h after injury, and less severe BBB damage after injury. Most inflammatory cytokine expressions and the number of apoptotic cells in the brain tissue of mice in the CCI+DC group were lower than in the CCI group at 3 days after injury, with markedly reduced astrocyte and microglia expression. However, the degree of brain edema in the CCI+DC group was greater than in the CCI group, and neurological and motor functions, as well as spatial cognitive and learning ability, were significantly poorer at 14 days after injury.
Collapse
Affiliation(s)
- Yuheng Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Zhijuan Chen
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuanzhi Wang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
- Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Junjie Gong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Anqi He
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Mingyu Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Chen Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Weidong Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Weidong Yang
| | - Zengguang Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
- *Correspondence: Zengguang Wang
| |
Collapse
|
5
|
Borazjani R, Ajdari MR, Niakan A, Yousefi O, Amoozandeh A, Sayadi M, Khalili H. Current Status and Outcomes of Critical Traumatic Brain Injury (GCS = 3-5) in a Developing Country: A Retrospective, Registry-Based Study. World J Surg 2022; 46:2335-2343. [PMID: 35789431 DOI: 10.1007/s00268-022-06645-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients sustaining critical TBI [initial Glasgow Coma Scale (GCS) ≤ 5] generally have poor outcomes. Little is known about the frequency, mortality rate, and functional outcomes of such patients in Iran. METHODS In this retrospective, registry-based cohort study, the demographic and clinicoradiological findings of TBI patients were queried from March 21, 2017, to March 21, 2020. We included TBI patients with initial GCS of 3-5. The functional outcome was assessed using the Glasgow Outcome Score-extended 6 (GOSE-6) months after the hospital discharge. Patients were classified as having unfavorable (GOSE-6 ≤ 4) and favorable (GOSE-6 > 4) outcomes. Gathered data were compared between groups. Multivariable logistic regression analysis was done to find factors affecting the outcome. RESULTS Four hundred ninety-seven patients (mean age = 37.59 ± 17.89) were enrolled, and 69.2% had unfavorable outcomes. Elderly patients (age ≥ 65 years) were highly overrepresented among the unfavorable group. 48.9% had bilateral fixed dilated pupils (BDFP), who mostly attained unfavorable outcomes. The overall in-hospital mortality rate was 50.3%. The in-hospital mortality rate was appalling among elderly patients with BFDP and GCS 3( 90%) and GCS 4(100%). Age ≥ 65 years [odds ratio (OR) 3.45, 95% confidence interval (CI) 1.19-10.04], and BFDP (OR 4.48, 95% CI 2.60-7.73) increase the odds of unfavorable outcomes according to the regression analysis. CONCLUSION The survival rate and favorable outcomes of critical TBI patients are generally poor. However, we believe that the neurotrauma surgeons should discuss with patients' proxies and explain the clinical conditions and possible outcomes.
Collapse
Affiliation(s)
- Roham Borazjani
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Reza Ajdari
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Niakan
- Department of Neurosurgery, Trauma Research Center, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Chamran Blvd, Shiraz, 7194815711, Iran
| | - Omid Yousefi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arsham Amoozandeh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrab Sayadi
- Department of Biostatistics, Cardiovascular Research Center,, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hosseinali Khalili
- Department of Neurosurgery, Trauma Research Center, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Chamran Blvd, Shiraz, 7194815711, Iran.
| |
Collapse
|
6
|
Tang Z, Yang R, Zhang J, Huang Q, Zhou X, Wei W, Jiang Q. Outcomes of Traumatic Brain-Injured Patients With Glasgow Coma Scale < 5 and Bilateral Dilated Pupils Undergoing Decompressive Craniectomy. Front Neurol 2021; 12:656369. [PMID: 34113309 PMCID: PMC8185205 DOI: 10.3389/fneur.2021.656369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Decompressive craniectomy (DC) plays an important role in the treatment of patients with severe traumatic brain injury (sTBI) with mass lesions and intractably elevated intracranial hypertension (ICP). However, whether DC should be performed in patients with bilateral dilated pupils and a low Glasgow Coma Scale (GCS) score is still controversial. This retrospective study explored the clinical outcomes and risk factors for an unfavorable prognosis in sTBI patients undergoing emergency DC with bilateral dilated pupils and a GCS score <5. Methods: The authors reviewed the data from patients who underwent emergency DC from January 2012 to March 2019 in a medical center in China. All data, such as patient demographics, radiological findings, clinical parameters, and preoperative laboratory variables, were extracted. Multivariate logistic regression analysis was performed to determine the factors associated with 30-day mortality and 6-month negative neurological outcome {defined as death or vegetative state [Glasgow Outcome Scale (GOS) score 1-2]}. Results: A total of 94 sTBI patients with bilateral dilated pupils and a GCS score lower than five who underwent emergency DC were enrolled. In total, 74 patients (78.7%) died within 30 days, and 84 (89.4%) had a poor 6-month outcome (GOS 1-2). In multivariate analysis, advanced age (OR: 7.741, CI: 2.288-26.189), prolonged preoperative activated partial thromboplastin time (aPTT) (OR: 7.263, CI: 1.323-39.890), and low GCS (OR: 6.162, CI: 1.478-25.684) were associated with a higher risk of 30-day mortality, while advanced age (OR: 8.812, CI: 1.817-42.729) was the only independent predictor of a poor 6-month prognosis in patients undergoing DC with preoperative bilateral dilated pupils and a GCS score <5. Conclusions: The mortality and disability rates are extremely high in severe TBI patients undergoing emergency DC with bilateral fixed pupils and a GCS score <5. DC is more valuable for younger patients.
Collapse
Affiliation(s)
- Zhiji Tang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Ruijin Yang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Jinshi Zhang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Qianliang Huang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Xiaoping Zhou
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Wenjin Wei
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| | - Qiuhua Jiang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, China
| |
Collapse
|
7
|
Ndiaye Sy EHC, Cisse Y, Thiam AB, Barry LF, Mbaye M, Diop A, Thioub M, Faye M, Fahad A, Ndongo MM, Soilihi AA, Doumbia N, Codé Ba M, Badiane SB. Decompressive craniectomy: indications and results of 24 cases at the neurosurgery clinic of Fann university hospital of Dakar. Pan Afr Med J 2021; 38:399. [PMID: 34381543 PMCID: PMC8325445 DOI: 10.11604/pamj.2021.38.399.27571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/22/2021] [Indexed: 11/28/2022] Open
Abstract
Decompressive craniectomy is a surgical technique considered to be the last step in the management of intracranial hypertension. The objective of our study was to evaluate our results in the management of intracranial hypertension by decompressive craniectomy. This was a retrospective study of 24 cases of decompressive craniectomy performed over a 9-year period (from January 2010 to December 2019) at the Fann Neurosurgery Clinic. The mean age of the patients was 33.82 years, there was a male predominance with a sex ratio of 2.42. The most frequent indication was severe cranioencephalic trauma with 50%. The cerebral computed tomography (CT) scan was the key examination and was performed in all our patients. Complications were entirely infectious and were the cause of 73.33% of deaths. Thirty-five percent of the patients had received prior treatment before the decompressive craniectomy. The functional prognosis was good in 44.44% of cases, moderate in 33.33% of cases, 1 (11.11%) patient had a severe disability and 1 (11.11%) patient was in a vegetative state. Mortality rate was 62.5% of patients in our study series. Despite the lack of sophisticated techniques for diagnosis and monitoring of intracranial hypertension, our results remain acceptable with 37.5% survival. The early completion of this surgery allows us to be more efficient with a significant reduction in morbidity and mortality.
Collapse
Affiliation(s)
| | - Yakhya Cisse
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | | | | | - Maguette Mbaye
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | - Abdoulaye Diop
- Neurosurgery Unit, Ziguinchor Regional Hospital, Ziguinchor, Senegal
| | - Mbaye Thioub
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | - Mohameth Faye
- Neurosurgery Department, Idrissa Pouye General Hospital, Dakar, Senegal
| | - Attoumane Fahad
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | | | | | - Nantenin Doumbia
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | - Momar Codé Ba
- Neurosurgery Department, Fann University Hospital Center, Dakar, Senegal
| | | |
Collapse
|
8
|
Prognostic Analysis of Emergency Decompressive Craniectomy for Patients with Severe Traumatic Brain Injury with Bilateral Fixed Dilated Pupils. World Neurosurg 2020; 146:e1307-e1317. [PMID: 33307262 DOI: 10.1016/j.wneu.2020.11.162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/27/2020] [Accepted: 11/28/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE For patients with severe traumatic brain injury (sTBI) with bilateral fixed dilated pupils (BFDP), the value of aggressively decompressive craniectomy (DC) treatment is still controversial. The objective of this study was to analyze and validate the outcome of DC in patients with sTBI with BFDP. METHODS We retrospectively collected data from 44 patients with sTBI with BFDP who underwent DC treatment from July 2011 to June 2018. Outcomes used as indicators were mortality and favorable outcome. The analysis was based on the Glasgow Outcome Scale score recorded at discharge, 6, and 12 months after trauma. RESULTS The overall survival was 36.4% (16/44) at discharge and 25.0% (11/44) at 6 and 12 months, and the favorable outcome (Glasgow Outcome Scale score = 4-5) at discharge, 6, and 12 months after injury was 9.1% (4/44), 13.6% (6/44), and 20.5% (9/44), respectively. Sex (P = 0.046), preoperative Glasgow Coma Scale (GCS) score (P = 0.031), injury-surgery intervals (P = 0.022), and tracheotomy (P = 0.017) were independent associations to 6 and 12 months follow-up survival, whereas only preoperative GCS score (odds ratio, 6.088; confidence interval, 1.172-31.612; P = 0.032) and injury-surgery intervals (odds ratio, 0.241; confidence interval, 0.065-0.893; P = 0.033) were independent associations with 12 months follow-up favorable outcome. CONCLUSIONS BFDP indicates a grave prognostic sign after sTBI, but the higher preoperative GCS score and shorter injury-surgery intervals in patients who underwent DC treatment might independently predict favorable outcome for patients with sTBI with BFDP, and patients might benefit more than expected if the DC treatment were applied more aggressively and positively.
Collapse
|
9
|
Jo K, Joo WI, Yoo DS, Park HK. Clinical Significance of Decompressive Craniectomy Surface Area and Side. J Korean Neurosurg Soc 2020; 64:261-270. [PMID: 33280352 PMCID: PMC7969045 DOI: 10.3340/jkns.2020.0149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Decompressive craniectomy (DC) can partially remove the unyielding skull vault and make affordable space for the expansion of swelling brain contents. The objective of this study was to compare clinical outcome according to DC surface area (DC area) and side.
Methods A total of 324 patients underwent different surgical methods (unilateral DC, 212 cases and bilateral DC, 112 cases) were included in this retrospective analysis. Their mean age was 53.4±16.6 years (median, 54 years). Neurological outcome (Glasgow outcome scale), ventricular intracranial pressure (ICP), and midline shift change (preoperative minus postoperative) were compared according to surgical methods and total DC area, DC surface removal rate (DC%) and side.
Results DC surgery was effective for ICP decrease (32.3±16.7 mmHg vs. 19.2±13.4 mmHg, p<0.001) and midline shift change (12.5±7.6 mm vs. 7.8±6.9 mm, p<0.001). The bilateral DC group showed larger total DC area (125.1±27.8 cm2 for unilateral vs. 198.2±43.0 cm2 for bilateral, p<0.001). Clinical outcomes were nonsignificant according to surgical side (favorable outcome, p=0.173 and mortality, p=0.470), significantly better when total DC area was over 160 cm2 and DC% was 46% (p=0.020 and p=0.037, respectively).
Conclusion DC surgery is effective in decrease the elevated ICP, decrease the midline shift and improve the clinical outcome in massive brain swelling patient. Total DC area and removal rate was larger in bilateral DC than unilateral DC but clinical outcome was not influenced by DC side. DC area more than 160 cm2 and DC surface removal rate more than 46% were more important than DC side.
Collapse
Affiliation(s)
- KwangWook Jo
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Il Joo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
10
|
Mizrahi CJ, Paldor I, Candanedo C, Mollica S, Itshayek E. Accuracy of freehand external ventricular drain placement in patients after a large decompressive hemicraniectomy. J Clin Neurosci 2020; 81:27-31. [PMID: 33222928 DOI: 10.1016/j.jocn.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/06/2020] [Indexed: 11/19/2022]
Abstract
Our study aim is to evaluate the accuracy of freehand external ventricular drain (EVD) placement, without the use of adjuncts to placement, immediately following a large decompressive hemicraniectomy (DC). We performed a retrospective cohort analysis comparing patients who underwent freehand EVD placement immediately after a DC, to those who underwent freehand EVD placement without DC. Computed tomography (CT) studies were used to assess accuracy based on catheter tip location. Intracranial catheter length, pre- and post-operative Evan's Index, and midline shift pre- and post-operatively were analysed as separate variables in each group. A previously described grading system was used to assess the accuracy of free hand EVD placement. There were a total 110 patients overall; DC group, n = 50; non-DC group, n = 60. There was a significant reduction from pre-operative midline shift to post-operative midline shift in the DC group (9.13 vs 6.02 mm; p = 0.0064). There was no significant difference in accuracy between the two groups (p = 0.8917), and similar rates of Grade 1 - i.e. optimal - catheter tip location (DC = 78% vs non-DC = 81%) were found. All analysed variables comparing both Grade 1 subgroups (pre- and postoperative Evan's Index, and midline shift) showed significant differences between them. Mean catheter length in Grade 1 EVD placement showed a statistically significant difference between the DC and non-DC groups (63.78 vs 59.96 mm, respectively; p = 0.009). An EVD, after DC for traumatic and non-traumatic intracranial pathologies, can be accurately placed by freehand.
Collapse
Affiliation(s)
- Cezar José Mizrahi
- Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.
| | - Iddo Paldor
- Department of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | - Carlos Candanedo
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Semira Mollica
- Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Eyal Itshayek
- Department of Neurosurgery, Rabin Medical Center, Petah Tikva, Israel
| |
Collapse
|
11
|
Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
Collapse
Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
| | | |
Collapse
|
12
|
In-Suk Bae MD, Hyoung-Joon Chun MD, Hyeong-Joong Yi MD, Kyu-Sun Choi MD. Using components of the Glasgow coma scale and Rotterdam CT scores for mortality risk stratification in adult patients with traumatic brain injury: A preliminary study. Clin Neurol Neurosurg 2019; 188:105599. [PMID: 31760257 DOI: 10.1016/j.clineuro.2019.105599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The Glasgow Coma Scale (GCS) and Rotterdam Computed Tomography Score (RCTS) are widely used to predict outcomes after traumatic brain injury (TBI). The objective of this study was to determine whether the GCS and RCTS components can be used to predict outcomes in patients with traumatic intracranial hemorrhage (IH) after TBI. PATIENTS AND METHODS Between May 2009 and July 2017, 773 patients with IH after TBI were retrospectively reviewed. Data on initial GCS, RCTS according to initial brain CT, and status at hospital discharge and last follow-up were collected. Logistic regression analysis was performed to evaluate the relationship between GCS and RCTS components with outcomes after TBI. RESULTS Among the 773 patients, the overall in-hospital mortality rate was 14.0%. Variables independently associated with outcomes were the verbal (V-GCS) and motor components of GCS (M-GCS), epidural mass lesion (E-RCTS) and intraventricular or subarachnoid hemorrhage components of RCTS (H-RCTS) (p < 0.0001). The new TBI score was obtained with the following calculation: [V-GCS + M-GCS] - [E-RCTS + H-RCTS]. CONCLUSION The new TBI score includes both clinical status and radiologic findings from patients with IH after TBI. The new TBI score is a useful tool for assessing TBI patients with IH in that it combines the GCS and RCTS components that increases area under the curve for predicting in-hospital mortality and unfavorable outcomes and eliminates the paradoxical relationship with outcomes which was observed in GCS score. It allows a practical method to stratify the risk of outcomes after TBI.
Collapse
Affiliation(s)
- M D In-Suk Bae
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - M D Hyoung-Joon Chun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea.
| | - M D Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| | - M D Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, South Korea
| |
Collapse
|
13
|
Tian R, Liu W, Dong J, Zhang J, Xu L, Zhang B, Tao X, Li J, Liu B. Prognostic Predictors of Early Outcomes and Discharge Status of Patients Undergoing Decompressive Craniectomy After Severe Traumatic Brain Injury. World Neurosurg 2019; 126:e101-e108. [PMID: 30790726 DOI: 10.1016/j.wneu.2019.01.246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- Runfa Tian
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Jinqian Dong
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Ji Zhang
- Department of Neurosurgery, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Long Xu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Bin Zhang
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Xiaogang Tao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Jingsheng Li
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China; China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China; Beijing Key Laboratory of Central Nervous System Injury, Beijing, People's Republic of China; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Beijing, People's Republic of China.
| |
Collapse
|
14
|
Kaushal A, Bindra A, Kumar A, Goyal K, Kumar N, Rath GP, Gupta D. Long Term Outcome in Survivors of Decompressive Craniectomy following Severe Traumatic Brain Injury. Asian J Neurosurg 2019; 14:52-57. [PMID: 30937008 PMCID: PMC6417309 DOI: 10.4103/ajns.ajns_147_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Decompressive craniectomy (DC) is done for the management of intracranial hypertension due to severe traumatic brain injury (sTBI). Despite DC, a number of patients die and others suffer from severe neurological disability. We conducted this observational study to assess functional outcome as measured by Glasgow outcome scale-extended (GOSE) in survivors of DC. The correlation between various factors at admission and hospital with functional outcome was also obtained. Materials and Methods: Patients (15–65 years) posted for cranioplasty following DC due to sTBI were prospectively enrolled. Demographic profile, clinical data, and GOSE were noted at the time of admission for cranioplasty from the patient or nearest relative or both. Retrospective data noted from hospital records included admission Marshalls grading, Glasgow coma score (GCS), motor response, mean arterial pressure (MAP), and timing of DC at the time of initial admission following sTBI. Results: A total of 85 patients (71 males and 14 females) were enrolled over a period of 2 years. The mean age of the patients was 33.42 ± 12.70 years. The median GCS at the time of admission due to head injury, at the time of discharge, and at the time of cranioplasty was 8 (interquartile range [IQR] 3–15), 10 (IQR 4–15), and 15 (IQR 7–15), respectively. Thirty-one patients (36%) had good functional outcome (GOSE 5–8) and 54 patients (64%) had poor functional outcome (GOSE 1–4). On univariate analysis tracheostomy (P = 0.00), duration of hospital stay (P = 0.002), MAP at admission (P = 0.01), and GCS at discharge (P = 0.01) correlated with outcome [Table 1]. On multivariate analysis MAP at admission (odds ratio [OR] [95% confidence interval {CI}]; 0.07 [0.01–0.40] and tracheostomy (OR [95% CI]; 15 [1.45–162.9]) were found to be the independent predictors of functional outcome. Conclusion: Significant disability is seen among the survivors of DC. Tracheostomy and MAP at admission were found to be independently associated with the patient outcome.
Collapse
Affiliation(s)
- Ashutosh Kaushal
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Ashish Bindra
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Abhyuday Kumar
- Department of Anesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Keshav Goyal
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Niraj Kumar
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Deepak Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| |
Collapse
|
15
|
Oernbo EK, Lykke K, Steffensen AB, Töllner K, Kruuse C, Rath MF, Löscher W, MacAulay N. Cerebral influx of Na + and Cl - as the osmotherapy-mediated rebound response in rats. Fluids Barriers CNS 2018; 15:27. [PMID: 30249273 PMCID: PMC6154956 DOI: 10.1186/s12987-018-0111-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/19/2018] [Indexed: 02/01/2023] Open
Abstract
Background Cerebral edema can cause life-threatening increase in intracranial pressure. Besides surgical craniectomy performed in severe cases, osmotherapy may be employed to lower the intracranial pressure by osmotic extraction of cerebral fluid upon intravenous infusion of mannitol or NaCl. A so-called rebound effect can, however, hinder continuous reduction in cerebral fluid by yet unresolved mechanisms. Methods We determined the brain water and electrolyte content in healthy rats treated with osmotherapy. Osmotherapy (elevated plasma osmolarity) was mediated by intraperitoneal injection of NaCl or mannitol with inclusion of pharmacological inhibitors of selected ion-transporters present at the capillary lumen or choroidal membranes. Brain barrier integrity was determined by fluorescence detection following intravenous delivery of Na+-fluorescein. Results NaCl was slightly more efficient than mannitol as an osmotic agent. The brain water loss was only ~ 60% of that predicted from ideal osmotic behavior, which could be accounted for by cerebral Na+ and Cl− accumulation. This electrolyte accumulation represented the majority of the rebound response, which was unaffected by the employed pharmacological agents. The brain barriers remained intact during the elevated plasma osmolarity. Conclusions A brain volume regulatory response occurs during osmotherapy, leading to the rebound response. This response involves brain accumulation of Na+ and Cl− and takes place by unresolved molecular mechanisms that do not include the common ion-transporting mechanisms located in the capillary endothelium at the blood–brain barrier and in the choroid plexus epithelium at the blood–CSF barrier. Future identification of these ion-transporting routes could provide a pharmacological target to prevent the rebound effect associated with the widely used osmotherapy.
Collapse
Affiliation(s)
- Eva Kjer Oernbo
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Lykke
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark.,AJVaccines, Copenhagen, Denmark
| | | | - Kathrin Töllner
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Christina Kruuse
- Neurovascular Research Unit, Department of Neurology, Herlev Gentofte Hospital, University of Copenhagen, Herlev, Copenhagen, Denmark
| | | | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Nanna MacAulay
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark. .,Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen, Denmark.
| |
Collapse
|
16
|
Cheng F, Xu M, Liu H, Wang W, Wang Z. A Retrospective Study of Intracranial Pressure in Head-Injured Patients Undergoing Decompressive Craniectomy: A Comparison of Hypertonic Saline and Mannitol. Front Neurol 2018; 9:631. [PMID: 30131757 PMCID: PMC6090152 DOI: 10.3389/fneur.2018.00631] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 07/12/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: The impact of hypertonic saline (HTS) on the control of increased intracranial pressure (ICP) in head-injured patients undergoing decompressive craniectomy (DC) has yet to be established. The current retrospective study was conducted to compare the effect of HTS and mannitol on lowering the ICP burden of these patients. Methods: We reviewed data on patients who had sustained a traumatic brain injury (TBI) and were admitted to the First People's Hospital of Kunshan between January 1, 2012, and August 31, 2017. Patients who received only one type of hyperosmotic agent, 3% HTS or 20% mannitol, after DC were included. The daily ICP burden (h/day) and response to the hyperosmolar agent were used as primary outcome measures. The numbers of days in the intensive care unit and in the hospital, and the 2-weeks mortality rates were also compared between the groups. Results: The 30 patients who received 3% HTS only and the 30 who received 20% mannitol only were identified for approximate matching and additional data analyses. The demographic characteristics of the patients in the two groups were comparable, but the daily ICP burden was significantly lower in the HTS group than in the mannitol group (0.89 ± 1.02 h/day vs. 2.11 ± 2.95 h/day, respectively; P = 0.038). The slope of the reduction in ICP in response to a bolus dose at baseline was higher with HTS than with mannitol (P = 0.001). However, the between-group difference in the 2-weeks mortality rates was not statistically significant (2 [HTS] vs. 1 [mannitol]; P = 0.554). Conclusion: When used in equiosmolar doses, the reduction in the ICP of TBI patients achieved with 3% HTS was superior to that achieved with 20% mannitol after DC. However, this advantage did not seem to confer any additional benefit terms of short-term mortality.
Collapse
Affiliation(s)
- Feng Cheng
- Department of Neurosurgery, Suzhou Kowloon Hospital, Soochow University, Suzhou, China.,Department of Neurosurgery, The First People's Hospital of Kunshan, Jiangsu University, Suzhou, China
| | - Min Xu
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Suzhou, China
| | - Hua Liu
- Department of Neurosurgery, The First People's Hospital of Kunshan, Jiangsu University, Suzhou, China
| | - Wenming Wang
- Department of Neurosurgery, The First People's Hospital of Kunshan, Jiangsu University, Suzhou, China
| | - Zhimin Wang
- Department of Neurosurgery, Suzhou Kowloon Hospital, Soochow University, Suzhou, China
| |
Collapse
|
17
|
Fomchenko EI, Gilmore EJ, Matouk CC, Gerrard JL, Sheth KN. Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas. Curr Treat Options Neurol 2018; 20:34. [PMID: 30019165 DOI: 10.1007/s11940-018-0518-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Management of patients with subdural hematomas starts with Emergency Neurological Life Support guidelines. Patients with acute or chronic subdural hematomas (SDHs) associated with rapidly deteriorating neurologic exam, unilaterally or bilaterally dilated nonreactive pupils, and extensor posturing are considered imminently surgical; likewise, SDHs more than 10 mm in size or those associated with more than 5-mm midline shift are deemed operative. RECENT FINDINGS While twist drill craniostomy and placement of subdural evacuating vport system (SEPS) are quick, bedside procedures completed under local anesthesia and appropriate for patients with chronic SDH or patients that cannot tolerate anesthesia, these techniques are not optimal for patients with acute SDH or chronic SDH with septations. Burr hole SDH evacuation under conscious sedation or general anesthesia is an analogous technique; however, it requires basic surgical equipment and operating room staff, with a focus on a closed system with burr hole followed by rapid drain placement to avoid introduction of air into the subdural space, or multiple burr holes with extensive irrigation to reduce pneumocephalus and continue SDH evacuation via drain for several days. Acute SDH associated with significant mass effect and cerebral edema requires aggressive decompression via craniotomy with clot evacuation and frequently a craniectomy. Chronic SDHs that fail conservative management and progress clinically or radiographically are addressed with craniotomy with or without membranectomy. Surgical SDH management is variable depending on its characteristics and etiology, patient's functional status, comorbidities, goals of care, institutional preferences, and availability of specialized surgical equipment and adjunct therapies. Rapid access to surgical suites and trained staff to address surgical hemorrhages in a timely manner, with appropriate post-operative care by a specialized team including neurosurgeons and neurointensivists, is of paramount importance for successful patient outcomes. Here, we review various aspects of surgical SDH management.
Collapse
Affiliation(s)
- Elena I Fomchenko
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA.
| | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Division of Neuro-Critical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA
| | - Jason L Gerrard
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Division of Neuro-Critical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Department of Clinical Neurosciences, Yale University, 20 York St, New Haven, CT, USA
| |
Collapse
|
18
|
Kim H, Suh SJ, Kang HJ, Lee MS, Lee YS, Lee JH, Kang DG. Predictable Values of Decompressive Craniectomy in Patients with Acute Subdural Hematoma: Comparison between Decompressive Craniectomy after Craniotomy Group and Craniotomy Only Group. Korean J Neurotrauma 2018; 14:14-19. [PMID: 29774193 PMCID: PMC5949517 DOI: 10.13004/kjnt.2018.14.1.14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/22/2018] [Accepted: 04/10/2018] [Indexed: 11/15/2022] Open
Abstract
Objective Patients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patients who primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranial hypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not require DC after craniotomy. Methods The 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primary craniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors were analyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors. Results Five factors showed significant differences between the two groups. They were the length of midline shifting to maximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p<0.001), coexistence of intraventricular hemorrhage (IVH) (p<0.001), traumatic intracerebral hemorrhage (TICH) (p=0.001), intraoperative findings showing intracranial hypertension combined with brain edema (p<0.001), and bleeding tendency (p=0.02). An average value of 2.74±1.52 was obtained for these factors for group A, which was significantly different from that for group B (p<0.001). Conclusion An MT ratio >1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signs of intracranial hypertension, brain edema, and bleeding tendency were identified as factors indicating that DC would be required. The necessity for preemptive DC must be carefully considered in patients with such risk factors.
Collapse
Affiliation(s)
- Hyunjun Kim
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Sang-Jun Suh
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Ho-Jun Kang
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Min-Seok Lee
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Yoon-Soo Lee
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Jeong-Ho Lee
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| | - Dong-Gee Kang
- Department of Neurosurgery, Daegu Fatima Hospital, Daegu, Korea
| |
Collapse
|
19
|
Liu H, Xu R, Yang J, Ren G, He S. Initial intracranial pressure as a prognosticator in head-injured patients undergoing decompressive craniectomy. Oncotarget 2018; 7:62657-62663. [PMID: 27577076 PMCID: PMC5308755 DOI: 10.18632/oncotarget.11632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/15/2016] [Indexed: 11/25/2022] Open
Abstract
Purpose To examine the prognostic discrimination and prediction of initial intracranial pressure (ICP) in patients with traumatic brain injury (TBI) undergoing decompressive craniectomy (DC). Results The relationship between the initial ICP value and prognosis was quantified, and higher values indicated worse patient outcomes. Univariate analysis showed that the initial ICP value was significantly associated with mortality (odds ratio: 1.272, 95% confidence interval: 1.116-1.449; P<0.001) and unfavorable outcomes (odds ratio: 1.256, 95% confidence interval: 1.160-1.360; P<0.001). After adjustment for related outcome predictors of TBI in multivariate regression, the initial ICP value remained an independent predictor of unfavorable outcomes (odds ratio: 1.251, 95% confidence interval: 1.140-1.374; P=0.015) and mortality (odds ratio: 1.162, 95% confidence interval: 1.093-1.321; P=0.019). Methods A retrospective study was conducted in 133 TBI patients after DC. Initial ICP was defined as the first ICP recorded during surgery. Mortality and Glasgow Outcome Scale score at the end of follow-up were used as outcome measures. Unfavorable and favorable outcomes were classified by a Glasgow Outcome Scale score of 1 to 3 and 4 to 5, respectively. We used binary logistic and proportional odds regression for prognostic analyses. Conclusion For TBI patients undergoing DC, the initial ICP value provides great prognostic discrimination and is an independent predictor of unfavorable outcomes and mortality. We suggest that the initial ICP be included as a prognosticator in the overall assessment of prognosis of head-injured patients after DC.
Collapse
Affiliation(s)
- Hua Liu
- Department of Neurosurgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou, Jiangsu, China
| | - Rong Xu
- Department of Pediatric Surgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou, Jiangsu, China
| | - Jian Yang
- Department of Neurosurgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou, Jiangsu, China
| | - Guanghui Ren
- Department of Neurosurgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou, Jiangsu, China
| | - Shengxue He
- Department of Neurosurgery, The Affiliated Brain Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| |
Collapse
|
20
|
Zhang S, Qian C, Sun G, Li X. Clinical application of the supraorbital key-hole approach to the treatment of unilateral-dominant bilateral frontal contusions. Oncotarget 2017; 8:48343-48349. [PMID: 28415664 PMCID: PMC5564652 DOI: 10.18632/oncotarget.15983] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/27/2017] [Indexed: 11/25/2022] Open
Abstract
We compared the surgical efficacy of the supraorbital key-hole approach (SKA) to conventional unilateral frontotemporal craniotomy (UFTC) for the treatment of patients with unilateral-dominant bilateral frontal contusions (BFCs). A retrospective analysis of 62 patients with unilateral-dominant BFCs who underwent surgery at our institute between 2014 and 2017 was performed. There were 26 patients who underwent SKA (group A) and 36 who underwent UFTC (group B). Postoperative computed tomography scans showed satisfactory evacuation of the frontal cerebral contusions in both groups (p > 0.05). There was less intraoperative blood loss in group A than group B (17.1 ± 4.55 vs. 67.6 ± 10.28 mL, p < 0.05). The operative time was also shorter in group A (82.7 ± 13.73 vs. 132.4 ± 9.17 min, p < 0.05). Postoperative bleeding occurred in three cases in group A and in only one case in group B (p > 0.05). The average length of hospitalization was shorter in group A than group B (7.3 ± 1.09 vs. 12.9 ± 1.71 days, p < 0.05). No differences in the Glasgow Outcome Scale were observed between the two groups after 6 months of follow-up (p > 0.05). Thus, compared to UFTC, SKA is associated with shorter operation times and less trauma to the surrounding brain tissue.
Collapse
Affiliation(s)
- Shuguang Zhang
- Department of Neurosurgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou, P. R. China
| | - Chunfa Qian
- Department of Neurosurgery, Affiliated Nanjing Brain Hospital, Nanjing Medical University, Nanjing, P. R. China
| | - Guan Sun
- Department of Neurosurgery, Fourth Affiliated Yancheng Hospital of Nantong University, Yancheng, P. R. China
| | - Xiaoliang Li
- Department of Neurosurgery, The First People's Hospital of Kunshan Affiliated with Jiangsu University, Suzhou, P. R. China
| |
Collapse
|
21
|
Brown DA, Wijdicks EFM. Decompressive craniectomy in acute brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:299-318. [PMID: 28187804 DOI: 10.1016/b978-0-444-63600-3.00016-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Decompressive surgery to reduce pressure under the skull varies from a burrhole, bone flap to removal of a large skull segment. Decompressive craniectomy is the removal of a large enough segment of skull to reduce refractory intracranial pressure and to maintain cerebral compliance for the purpose of preventing neurologic deterioration. Decompressive hemicraniectomy and bifrontal craniectomy are the most commonly performed procedures. Bifrontal craniectomy is most often utilized with generalized cerebral edema in the absence of a focal mass lesion and when there are bilateral frontal contusions. Decompressive hemicraniectomy is most commonly considered for malignant middle cerebral artery infarcts. The ethical predicament of deciding to go ahead with a major neurosurgical procedure with the purpose of avoiding brain death from displacement, but resulting in prolonged severe disability in many, are addressed. This chapter describes indications, surgical techniques, and complications. It reviews results of recent clinical trials and provides a reasonable assessment for practice.
Collapse
Affiliation(s)
- D A Brown
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - E F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic and Neurosciences Intensive Care Unit, Mayo Clinic Campus, Saint Marys Hospital, Rochester, MN, USA.
| |
Collapse
|
22
|
Xu W, Kaur H, Wang X, Li H. The Role of Magnetic Resonance Imaging in the Prediction of Minimally Conscious State After Traumatic Brain Injury. World Neurosurg 2016; 94:167-173. [PMID: 27392891 DOI: 10.1016/j.wneu.2016.06.123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 06/28/2016] [Accepted: 06/28/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To establish a simple and feasible model of magnetic resonance imaging (MRI) for prediction of minimally conscious state in unconscious patients (≥2 weeks) after severe traumatic brain injury (TBI). METHODS MRI examinations were performed in 73 patients 4.5 weeks ± 1.6 (range, 2-8 weeks) after TBI. Brain lesions on MRI, age, sex, cause of injury, Glasgow Coma Scale (GCS) score, and decompressive craniectomy were retrospectively analyzed. Outcome was assessed at 12 months from the onset of TBI. RESULTS Of 73 patients, 39 were minimally conscious and 34 were unconscious at the endpoint. Binary logistic regression demonstrated that cause of injury (P = 0.036), GCS score (P = 0.011), and lesions of the thalamus (P = 0.002) and brainstem (P = 0.012) shown on MRI were closely associated with the outcome of minimally conscious state. The overall correct prediction of the logistic model was 90.4%. CONCLUSIONS The combination of MRI findings and other clinical data offers neurosurgeons substantial information about primary and secondary injuries of the patients with TBI, which allows a more accurate prediction of prognosis than a single GCS score or MRI findings alone. The regression model established in this study is simple and effective in predicting long-term unconscious state and minimally conscious state in patients after severe TBI.
Collapse
Affiliation(s)
- Weiwei Xu
- Department of Neurosurgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Harpreet Kaur
- Baba Farid University of Health Sciences, Faridkot, Punjab, India
| | - Xiangyu Wang
- Department of Neurosurgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.
| | - Hengguo Li
- Department of Neurosurgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| |
Collapse
|
23
|
Abstract
Decompressive craniectomy (DC) has been used for many years in the management of patients with elevated intracranial pressure and cerebral edema. Ongoing clinical trials are investigating the clinical and cost effectiveness of DC in trauma and stroke. While DC has demonstrable efficacy in saving life, it is accompanied by a myriad of non-trivial complications that have been inadequately highlighted in prospective clinical trials. Missing from our current understanding is a comprehensive analysis of all potential complications associated with DC. Here, we review the available literature, we tabulate all reported complications, and we calculate their frequency for specific indications. Of over 1500 records initially identified, a final total of 142 eligible records were included in our comprehensive analysis. We identified numerous complications related to DC that have not been systematically reviewed. Complications were of three major types: (1) Hemorrhagic (2) Infectious/Inflammatory, and (3) Disturbances of the CSF compartment. Complications associated with cranioplasty fell under similar major types, with additional complications relating to the bone flap. Overall, one of every ten patients undergoing DC may suffer a complication necessitating additional medical and/or neurosurgical intervention. While DC has received increased attention as a potential therapeutic option in a variety of situations, like any surgical procedure, DC is not without risk. Neurologists and neurosurgeons must be aware of all the potential complications of DC in order to properly advise their patients.
Collapse
|
24
|
Oh CH, Shim YS, Yoon SH, Hyun D, Park H, Kim E. Early Decompression of Acute Subdural Hematoma for Postoperative Neurological Improvement: A Single Center Retrospective Review of 10 Years. Korean J Neurotrauma 2016; 12:11-7. [PMID: 27182496 PMCID: PMC4866559 DOI: 10.13004/kjnt.2016.12.1.11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 01/06/2016] [Accepted: 02/10/2016] [Indexed: 11/15/2022] Open
Abstract
Objective This study was conducted to investigate survival related factors, as well as to evaluate the effects of early decompression on acute subdural hematoma (ASDH). Methods We retrospectively reviewed cases of decompressive craniectomy (DC) for decade. In total, 198 cases of DC involved ASDH were available for review, and 65 cases were excluded due to missing data on onset time and a delayed operation after closed observation with medical care. Finally, 133 cases of DC with ASDH were included in this study, and various factors including the time interval between trauma onset and operation were evaluated. Results In the present study, survival rate after DC in patients with ASDH was shown to be related to patient age (50 years old, p=0.012), brain compression ratio (p=0.042) and brain stem compression (p=0.020). Sex, preoperative mental status, and time interval between trauma onset and operation were not related with survival rate. Among those that survived (n=78), improvements in Glasgow Coma Scale (GCS) score of more than three points, compared to preoperative measurement, were more frequently observed among the early (less than 3 hours between trauma onset and operation) decompressed cases (p=0.013). However, improvements of more than 4 or 5 points on the GCS were not affected by early decompression. Conclusion Early decompression of ASDH was not correlated with survival rate, but was related with neurological improvement (more than three points on the GCS). Accordingly, early decompression in ASDH, if indicated, may be of particular benefit.
Collapse
Affiliation(s)
- Chang Hyun Oh
- Department of Neurosurgery, Guro Teun Teun Research Institute, Seoul, Korea
| | - Yu Shik Shim
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Seung Hwan Yoon
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Dongkeun Hyun
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Hyeonseon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| | - Eunyoung Kim
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
| |
Collapse
|
25
|
Chen W, Guo J, Wu J, Peng G, Huang M, Cai C, Yang Y, Wang S. Paradoxical Herniation After Unilateral Decompressive Craniectomy Predicts Better Patient Survival: A Retrospective Analysis of 429 Cases. Medicine (Baltimore) 2016; 95:e2837. [PMID: 26945365 PMCID: PMC4782849 DOI: 10.1097/md.0000000000002837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 01/21/2016] [Accepted: 01/26/2016] [Indexed: 02/05/2023] Open
Abstract
Paradoxical herniation (PH) is a life-threatening emergency after decompressive craniectomy. In the current study, we examined patient survival in patients who developed PH after decompressive craniectomy versus those who did not. Risk factors for, and management of, PH were also analyzed. This retrospective analysis included 429 consecutive patients receiving decompressive craniectomy during a period from January 2007 to December 2012. Mortality rate and Glasgow Outcome Scale (GOS) were compared between those who developed PH (n = 13) versus those who did not (n = 416). A stepwise multivariate logistic regression analysis was carried out to examine the risk factors for PH. The overall mortality in the entire sample was 22.8%, with a median follow-up of 6 months. Oddly enough, all 13 patients who developed PH survived beyond 6 months. Glasgow Coma Scale did not differ between the 2 groups upon admission, but GOS was significantly higher in subjects who developed PH. Both the disease type and coma degree were comparable between the 13 PH patients and the remaining 416 patients. In all PH episodes, patients responded to emergency treatments that included intravenous hydration, cerebral spinal fluid drainage discontinuation, and Trendelenburg position. A regression analysis indicated the following independent risk factors for PH: external ventriculostomy, lumbar puncture, and continuous external lumbar drainage. The rate of PH is approximately 3% after decompressive craniectomy. The most intriguing findings of the current study were the 0% mortality in those who developed PH versus 23.6% mortality in those who did not develop PH and significant difference of GOS score at 6-month follow-up between the 2 groups, suggesting that PH after decompressive craniectomy should be managed aggressively. The risk factors for PH include external ventriculostomy, ventriculoperitoneal shunt, lumbar puncture, and continuous external lumbar drainage.
Collapse
Affiliation(s)
- Weiqiang Chen
- From the Department of Neurosurgery, Fuzhou General Hospital of Nanjing Command, PLA, Fuzhou (WC, SW); Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, Shantou (WC, JG, JW, GP, YY); Department of Neurosurgery, Jieyang People's Hospital, Jieyang (MH); and Department of Neurosurgery (CC), Shantou Central Hospital, Shantou, Guangdong, China
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Zhao HX, Liao Y, Xu D, Wang QP, Gan Q, You C, Yang CH. Prospective randomized evaluation of therapeutic decompressive craniectomy in severe traumatic brain injury with mass lesions (PRECIS): study protocol for a controlled trial. BMC Neurol 2016; 16:1. [PMID: 26727957 PMCID: PMC4700654 DOI: 10.1186/s12883-015-0524-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 12/29/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND For cases of severe traumatic brain injury, during primary operation, neurosurgeons usually face a dilemma of whether or not to remove the bone flap after mass lesion evacuation. Decompressive craniectomy, which involves expansion of fixed cranial cavity, is used to treat intra-operative brain swelling and post-operative malignant intracranial hypertension. However, due to indefinite indication, the decision to perform this procedure heavily relies on personal experiences. In addition, decompressive craniectomy is associated with various complications, and the procedure lacks strong evidence of better outcomes. In the present study, we designed a prospective, randomized, controlled trial to clarify the effect of decompressive craniectomy in severe traumatic brain injury patients with mass lesions. METHODS PRECIS is a prospective, randomized, assessor-blind, single center clinical trial. In this trial, 336 patients with traumatic mass lesions will be randomly allocated to a therapeutic decompressive craniectomy group or a prophylactic decompressive craniectomy group. In the therapeutic decompressive craniectomy group, the bone flap will be removed or replaced depending on the emergence of brain swelling. In the prophylactic decompressive craniectomy group, the bone flap will be removed after mass lesion evacuation. A stepwise management of intracranial pressure will be provided according to the Brain Trauma Foundation guidelines. Salvage decompressive craniectomy will be performed for craniotomy patients once there is evidence of imaging deterioration and post-operative malignant intracranial hypertension. Participants will be assessed at 1, 6 and 12 months after randomization. The primary endpoint is favorable outcome according to the Extended Glasgow Outcome Score (5-8) at 12 months. The secondary endpoints include quality of life measured by EQ-5D, mortality, complications, intracranial pressure and cerebral perfusion pressure control and incidence of salvage craniectomy in craniotomy patients at each investigation time point. DISCUSSION This study will provide evidence to optimize primary decompressive craniectomy application and assess outcomes and risks for mass lesions in severe traumatic brain injury. TRIAL REGISTRATION ISRCTN20139421.
Collapse
Affiliation(s)
- He-xiang Zhao
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Yi Liao
- Department of Neuro-intensive care unit, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Ding Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Qiang-ping Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Qi Gan
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| | - Chao-hua Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Chengdu, Sichuan, 610041, P. R. China.
| |
Collapse
|
27
|
Sauvigny T, Göttsche J, Vettorazzi E, Westphal M, Regelsberger J. New Radiologic Parameters Predict Clinical Outcome after Decompressive Craniectomy. World Neurosurg 2015; 88:519-525.e1. [PMID: 26548831 DOI: 10.1016/j.wneu.2015.10.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 10/18/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is an established part of the management of patients with increased intracranial pressure due to malignant middle cerebral artery (MCA) infarction or traumatic brain injury (TBI). The aim of this study was to determine prognostic radiologic parameters regarding the functional outcome of patients with increased intracranial pressure (ICP) undergoing DC. Special focus was put on the potential differences between malignant MCA infarction and TBI. METHODS A total of 113 patients were analyzed for their clinical course where preoperative and postoperative radiologic features in computed tomography (CT) scans were correlated to the clinical outcome assessed by the Glasgow Outcome Scale. The difference between presurgical and postsurgical midline shift (ΔMLS) and the ratio between the diameter of the affected and contralateral hemisphere (HDratio) in presurgical and postsurgical CT scans were calculated. RESULTS ΔMLS (MCA infarction group) and postsurgical HDratio (TBI group) were found to be highly correlating with the clinical outcome on Spearman-correlation testing and underwent further analysis using a binary logistic regression model to evaluate their prognostic value on the outcome, which showed the predictive power of ΔMLS in malignant MCA infarction patients (odds ratio [OR] 0.715; confidence interval [CI] 0.551-0.865). Postsurgical HDratio correlated significantly (OR 0.620; CI 0.384-0.901) with the outcome in the TBI group. CONCLUSION ΔMLS is an objectifiable parameter, predicting outcome in malignant MCA infarction. In contrast, ΔMLS was of no predictive value in TBI patients. Here postsurgical HDratio serves as a strong predictor of clinical outcome. We recommend applying postsurgical HDratio to TBI patients in order to estimate their clinical outcome and adjust treatment.
Collapse
Affiliation(s)
- Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jennifer Göttsche
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
28
|
Mao X, Miao G, Hao S, Tao X, Hou Z, Li H, Tian R, Zhang H, Lu T, Ma J, Zhang X, Cheng H, Liu B. Decompressive craniectomy for severe traumatic brain injury patients with fixed dilated pupils. Ther Clin Risk Manag 2015; 11:1627-33. [PMID: 26543370 PMCID: PMC4622445 DOI: 10.2147/tcrm.s89820] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The outcome of decompressive craniectomy (DC) for severe traumatic brain injury (sTBI) patients with fixed dilated pupils (FDPs) is not clear. The objective of this study was to validate the outcome of DC in sTBI patients with FDPs. PATIENTS We retrospectively collected data from 207 sTBI patients with FDPs during the time period of May 4, 2003-October 22, 2013: DC group (n=166) and conservative care (CC) group (n=41). MEASUREMENTS Outcomes that were used as indicators in this study were mortality and favorable outcome. The analysis was based on the Glasgow Outcome Scale recorded at 6 months after trauma. RESULTS A total of 49.28% patients died (39.76% [DC group] vs 87.80% [CC group]). The mean increased intracranial pressure values after admission before operation were 36.20±7.55 mmHg in the DC group and 35.59±8.18 mmHg in the CC group. After performing DC, the mean ICP value was 14.38±2.60 mmHg. Approximately, 34.34% sTBI patients with FDPs in the DC group gained favorable scores and none of the patients in the CC group gained favorable scores. CONCLUSION We found that DC plays a therapeutic role in sTBI patients with FDPs, and it is particularly important to reduce intracranial pressure as soon as possible after trauma. For the patients undergoing DC, favorable outcome and low mortality could be achieved.
Collapse
Affiliation(s)
- Xiang Mao
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Guozhuan Miao
- Department of Neurotrauma, General Hospital of Armed Police Forces, Capital Medical University, Beijing, People's Republic of China
| | - Shuyu Hao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Xiaogang Tao
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Zonggang Hou
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Huan Li
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Runfa Tian
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Hao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China ; Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China ; Department of Neurotrauma, General Hospital of Armed Police Forces, Capital Medical University, Beijing, People's Republic of China
| | - Te Lu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Jun Ma
- Imaging Center of Neuroscience, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaodong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Hongwei Cheng
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People's Republic of China ; Nerve Injury and Repair Center of Beijing Institute for Brain Disorders, Capital Medical University, Beijing, People's Republic of China ; Neurotrauma Laboratory, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China ; Department of Neurotrauma, General Hospital of Armed Police Forces, Capital Medical University, Beijing, People's Republic of China
| |
Collapse
|
29
|
Szczygielski J, Mautes AE, Müller A, Sippl C, Glameanu C, Schwerdtfeger K, Steudel WI, Oertel J. Decompressive Craniectomy Increases Brain Lesion Volume and Exacerbates Functional Impairment in Closed Head Injury in Mice. J Neurotrauma 2015; 33:122-31. [PMID: 26102497 DOI: 10.1089/neu.2014.3835] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Decompressive craniectomy has been widely used in patients with head trauma. The randomized clinical trial on an early decompression (DECRA) demonstrated that craniectomy did not improve the neurological outcome, in contrast to previous animal experiments. The goal of our study was to analyze the effect of decompressive craniectomy in a murine model of head injury. Male mice were assigned into the following groups: sham, decompressive craniectomy, closed head injury (CHI), and CHI followed by craniectomy. At 24 h post-trauma, animals underwent the Neurological Severity Score test (NSS) and Beam Balance Score test (BBS). At the same time point, magnetic resonance imaging was performed, and volume of edema and contusion was assessed, followed by histopathological analysis. According to NSS, animals undergoing both trauma and craniectomy presented the most severe neurological impairment. Also, balancing time was reduced in this group compared with sham animals. Both edema and contusion volume were increased in the trauma and craniectomy group compared with sham animals. Histopathological analysis showed that all animals that underwent trauma presented substantial neuronal loss. In animals treated with craniectomy after trauma, a massive increase of edema with hemorrhagic transformation of contusion was documented. Decompressive craniectomy applied after closed head injury in mice leads to additional structural and functional impairment. The surgical decompression via craniectomy promotes brain edema formation and contusional blossoming in our model. This additive effect of combined mechanical and surgical trauma may explain the results of the DECRA trial and should be explored further in experiments.
Collapse
Affiliation(s)
- Jacek Szczygielski
- 1 Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine , Homburg/Saar, Germany
| | - Angelika E Mautes
- 1 Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine , Homburg/Saar, Germany
| | - Andreas Müller
- 2 Department of Radiology, Saarland University Medical Center and Saarland University Faculty of Medicine , Homburg/Saar, Germany
| | - Christoph Sippl
- 1 Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine , Homburg/Saar, Germany
| | - Cosmin Glameanu
- 1 Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine , Homburg/Saar, Germany
| | - Karsten Schwerdtfeger
- 1 Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine , Homburg/Saar, Germany
| | - Wolf-Ingo Steudel
- 1 Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine , Homburg/Saar, Germany
| | - Joachim Oertel
- 1 Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine , Homburg/Saar, Germany
| |
Collapse
|
30
|
Hu Y, Sun H, Yuan Y, Li Q, Huang S, Jiang S, Liu K, Yang C. Acute bilateral mass-occupying lesions in non-penetrating traumatic brain injury: a retrospective study. BMC Surg 2015; 15:6. [PMID: 25618576 PMCID: PMC4324851 DOI: 10.1186/1471-2482-15-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 01/15/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Traumatic acute bilateral mass-occupying lesions (TABML) is a common entity in head injury, with high morbidity and mortality. Our aim in this study was to evaluate the benefits of different treatment options and the outcome predictors in patients with TABML. METHODS From October 2010 to November 2012, a consecutive cohort of patients aged 16-70 years with TABML were retrospectively analyzed based on the clinical and radiological characteristics. Patients with TABML were included if admitted within 24 h after injury and were excluded if they presented with infratentorial lesions, unilateral lesions within the first 24 h after injury, or penetrating head injury. According to their treatment option, patients were divided into three groups: a conservative treatment group, a unilateral surgery group, and a bilateral surgery group. Outcomes were assessed using the Glasgow Outcome Scale (GOS). Binary logistic regression analysis was applied to determine the outcome predictors. RESULTS Forty-seven patients (58.8%) had severe injuries (Glasgow Coma Scale score (GCS), 3-8) upon admission, and the overall mortality was 31.3% at 6 months post-injury. The mortality was 55.6% in patients who underwent conservative treatment (N = 18), 17.9% in unilateral surgery patients (N = 39), and 34.8% in the bilateral surgery group (N = 23). In the surgical group, the mortality was 53.3% (8 of 15) in those with a GCS of 3-5, which decreased steeply to 14.9% (7 of 47) of those with GCS ≥ 6. On logistic regression analysis, the absence of pupillary reactivity, disappearances of basal cisterns and conservative treatment were related to higher mortality. A lower initial GCS score was associated with an unfavorable outcome. Midline shift tended to be associated with mortality and an unfavorable outcome, although statistical analysis did not show a significant difference. CONCLUSIONS TABML is suggestive of severe brain injury. As conservative treatment is always associated with a poorer outcome, surgery is advocated, especially in patients with a GCS score of ≥ 6. Whereas the prognostic value of midline shift might be limited because of the counter-mass effect in TABML, the GCS score, the pupillary reactivity, and particularly, the compression of basal cisterns should be emphasized.
Collapse
Affiliation(s)
- Yu Hu
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Hong Sun
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Yanqing Yuan
- />Department of Orthopedics, Hospital of Chengdu Office People’s Government of Tibetan Autonomous Region, Chengdu, Sichuan Province China
| | - Qiang Li
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Siqing Huang
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Shu Jiang
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| | - Kaili Liu
- />Department of Neurosurgery, Xindu District People’s Hospital of Chengdu, Chengdu, Sichuan Province China
| | - Chaohua Yang
- />Department of Neurosurgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, Sichuan Province China
| |
Collapse
|
31
|
Abstract
Abstract:Background:Intracranial hypertension can cause secondary damage after a traumatic brain injury. Aggressive medical management might not be sufficient to alleviate the increasing intracranial pressure (ICP), and decompressive craniectomy (DC) can be considered. Decompressive craniectomy can be divided into categories, according to the timing and rationale for performing the procedure: primary (done at the time of mass lesion evacuation) and secondary craniectomy (done to treat refractory ICP). Most studies analyze primary and secondary DC together. Our hypothesis is that these two groups are distinct and the aim of this retrospective study is to evaluate the differences in order to better predict outcome after DC.Methods:Seventy patients had DC over a period of four years at our center. They were divided into two groups based on the timing of the DC. Primary DC (44 patients) was done within 24 hours of the injury for mass lesion evacuation. Secondary DC (26 patients) was done after 24 hours and purely for the treatment of refractory ICP. Pre-op characteristics and post-op outcomes were compared between the two groups.Results:There was a significant difference in the mechanism of injury, the pupil abnormalities and Marshall grade between primary and secondary DC. There was also a significant difference in outcome with primary DC showing 45.5% good outcome and 40.9% mortality and secondary DC showing 73.1% good outcome and 15.4% mortality.Conclusions:Primary and secondary DC have different indications and patients characteristics. Outcome prediction following DC should be adjusted according to the surgical indication.
Collapse
|
32
|
Park JH, Park JE, Kim SH, Lim YC, You NK, Ahn YH, Choi HY, Cho JM. Outcomes of Ultra-Early Decompressive Craniectomy after Severe Traumatic Brain Injury-Treatment Outcomes after Severe TBI. Korean J Neurotrauma 2014; 10:112-8. [PMID: 27169044 PMCID: PMC4852600 DOI: 10.13004/kjnt.2014.10.2.112] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 12/03/2022] Open
Abstract
Objective The beneficial effect of decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial, but there is no debate that decompression should be performed before irreversible neurological deficit occurs. The aim of our study was to assess the value of ultra-early decompressive craniectomy in patients with severe TBI. Methods Total of 127 patients who underwent decompressive craniectomy from January 2007 to December 2013 was included in this study. Among them, 60 patients had underwent ultra-early (within 4 hours from injury) emergent operation for relief of increased intracranial pressure. Initial Glasgow coma scale, brain computed tomography (CT) scan features by Marshall CT classification, and time interval between injury and craniectomy were evaluated retrospectively. Clinical outcome was evaluated, using the modified Rankin score. Results The outcomes of ultra-early decompressive craniectomy group were not better than those in the comparison group (p=0.809). The overall mortality rate was 68.5% (87 patients). Six of all patients (4.7%) showed good outcomes, and 34 patients (26.8%) remained in a severely disabled or vegetative state. Forty of sixty patients (66.7%) had died, and two patients (3.3%) showed good outcomes at last follow-up. Conclusion Ultra-early decompressive craniectomy for intracranial hypertension did not improve patient outcome when compared with "early or late" decompressive craniectomy for managing severe TBI.
Collapse
Affiliation(s)
- Jun-Hee Park
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
| | - Jung-Eon Park
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
| | - Se-Hyuk Kim
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
| | - Yong-Cheol Lim
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
| | - Nam-Kyu You
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
| | - Young-Hwan Ahn
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
| | - Hyun-Yong Choi
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
| | - Jin-Mo Cho
- Department of Neurosurgery, Catholic Kwandong University International St. Mary's Hospital, Incheon, Korea
| |
Collapse
|
33
|
Wang CC, Chen YS, Lin BS, Chio CC, Hu CY, Kuo JR. The neuronal protective effects of local brain cooling at the craniectomy site after lateral fluid percussion injury in a rat model. J Surg Res 2013; 185:753-62. [DOI: 10.1016/j.jss.2013.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 06/08/2013] [Accepted: 07/02/2013] [Indexed: 10/26/2022]
|
34
|
Posttraumatic refractory intracranial hypertension and brain herniation syndrome: cerebral hemodynamic assessment before decompressive craniectomy. BIOMED RESEARCH INTERNATIONAL 2013; 2013:750809. [PMID: 24377095 PMCID: PMC3860083 DOI: 10.1155/2013/750809] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 10/17/2013] [Indexed: 11/30/2022]
Abstract
Background. The pathophysiology of traumatic brain swelling remains little understood. An improved understanding of intracranial circulatory process related to brain herniation may have treatment implications. Objective. To investigate the cerebral hemodynamic changes associated with brain herniation syndrome due to traumatic brain swelling. Methods. Nineteen head-injured patients with evidence of refractory intracranial hypertension and transtentorial herniation were prospectively studied. Cerebral hemodynamic assessment by transcranial Doppler (TCD) ultrasonography was performed prior to decompressive craniectomy. Patients and their cerebral hemispheres were classified according to TCD-hemodynamic patterns, and the data correlated with neurological status, midline shift on CT scan, and Glasgow outcome scale scores at 6 months after injury. Results. A wide variety of cerebral hemodynamic findings were observed. Ten patients (52.7%) presented with cerebral oligoemia, 3 patients (15.8%) with cerebral hyperemia, and 6 patients with nonspecific circulatory pattern. Circulatory disturbances were more frequently found in the side of maximal cerebral swelling than in the opposite side. Pulsatility index (PI) values suggested that ICP varied from acceptable to considerably high; patients with increased PI, indicating higher microvascular resistance. No correlation was found between cerebral hemodynamic findings and outcome. Conclusions. There is a marked heterogeneity of cerebral hemodynamic disturbances among patients with brain herniation syndrome.
Collapse
|
35
|
Is timing of cranioplasty following posttraumatic craniectomy related to neurological outcome? Int J Surg 2013; 11:886-90. [DOI: 10.1016/j.ijsu.2013.07.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 06/18/2013] [Accepted: 07/27/2013] [Indexed: 11/30/2022]
|
36
|
Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
37
|
|
38
|
Tuzgen S, Kucukyuruk B, Aydin S, Ozlen F, Kizilkilic O, Abuzayed B. Decompressive craniectomy in patients with cerebral infarction due to malignant vasospasm after aneurysmal subarachnoid hemorrhage. J Neurosci Rural Pract 2012. [PMID: 23188970 PMCID: PMC3505309 DOI: 10.4103/0976-3147.102598] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIM The authors present their experience and the clinical results in decompressive craniectomy (DC) in patients with vasospasm after aneurysmal subarachnoid hemorrhage (SAH). MATERIALS AND METHODS Between 2002 and 2010, six patients underwent DC due to cerebral infarct and edema secondary to vasospasm after aneurysmal SAH. Four patients were male, and two were female. The age of patients ranged between 33 and 60 (mean: 47,6 ± 11,4). The follow up period ranged between 12 to 104 months (mean: 47,6 ± 36,6). The SAH grading according World Federation of Neurosurgeons (WFNS) score ranged between 3 to 5. RESULTS Last documented modified Rankin Score (mRS) ranged between 2 to 6. One patient died in the following year after decompression due to pneumonia and sepsis. Two patients had moderate disability (mRS of 4) and three patients continue their life with minimal deficit and no major dependency (mRS score 2 and 3). CONCLUSION DC can be a life-saving procedure which provides a better outcome in patients with cerebral infarction secondary to vasospasm and SAH. However, the small number of the patients in this study is the main limitation of the accuracy of the results, and more studies with larger numbers are required to evaluate the efficiency of DC in this group of patients.
Collapse
Affiliation(s)
- Saffet Tuzgen
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | | | | | | | | | | |
Collapse
|
39
|
|
40
|
Bor-Seng-Shu E, Figueiredo EG, Amorim RLO, Teixeira MJ, Valbuza JS, de Oliveira MM, Panerai RB. Decompressive craniectomy: a meta-analysis of influences on intracranial pressure and cerebral perfusion pressure in the treatment of traumatic brain injury. J Neurosurg 2012; 117:589-96. [PMID: 22794321 DOI: 10.3171/2012.6.jns101400] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECT In recent years, the role of decompressive craniectomy for the treatment of traumatic brain injury (TBI) in patients with refractory intracranial hypertension has been the subject of several studies. The purpose of this review was to evaluate the contribution of decompressive craniectomy in reducing intracranial pressure (ICP) and increasing cerebral perfusion pressure (CPP) in these patients. METHODS Comprehensive literature searches were performed for articles related to the effects of decompressive craniectomy on ICP and CPP in patients with TBI. Inclusion criteria were as follows: 1) published manuscripts, 2) original articles of any study design except case reports, 3) patients with refractory elevated ICP due to traumatic brain swelling, 4) decompressive craniectomy as a type of intervention, and 5) availability of pre- and postoperative ICP and/or CPP data. Primary outcomes were ICP decrease and/or CPP increase for assessing the efficacy of decompressive craniectomy. The secondary outcome was the persistence of reduced ICP 24 and 48 hours after the operation. RESULTS Postoperative ICP values were significantly lower than preoperative values immediately after decompressive craniectomy (weighted mean difference [WMD] -17.59 mm Hg, 95% CI -23.45 to -11.73, p < 0.00001), 24 hours after (WMD -14.27 mm Hg, 95% CI -24.13 to -4.41, p < 0.00001), and 48 hours after (WMD -12.69 mm Hg, 95% CI -22.99 to -2.39, p < 0.0001). Postoperative CPP was significantly higher than preoperative values (WMD 7.37 mm Hg, 95% CI 2.32 to 12.42, p < 0.0001). CONCLUSIONS Decompressive craniectomy can effectively decrease ICP and increase CPP in patients with TBI and refractory elevated ICP. Further studies are necessary to define the group of patients that can benefit most from this procedure.
Collapse
Affiliation(s)
- Edson Bor-Seng-Shu
- Division of Neurological Surgery, Hospital das Clinicas, University of Sao Paulo School of Medicine, Brazil.
| | | | | | | | | | | | | |
Collapse
|
41
|
Operative and nonoperative linguistic outcomes in brain injury patients. J Neurol Sci 2012; 317:130-6. [PMID: 22418055 DOI: 10.1016/j.jns.2012.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 02/03/2012] [Accepted: 02/09/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE AND BACKGROUND Linguistic function is one of vulnerable aspects of traumatic brain injury (TBI) which may have destructive effects on patients' communicative activities and daily life, years following trauma. This paper attempts to answer the controversy whether surgery affects increase and decrease of linguistic impairment or not. MATERIALS AND METHODS Two hundred forty-one TBI patients aged 18-65 with abnormal CT findings and at least 20 minute post-trauma amnesia (PTA), who were conscious at discharge, participated in this study. Based on operative intervention, the samples were divided into two groups: operative and nonoperative. Cognitive and aphasic deficits were inspected formally and pragmatic disorder was informally appraised at discharge. RESULTS The groups had no significant differences in aphasia incidence and language pragmatic impairment, though they were significantly distinctive in aphasia subcategories and cognitive deficit after trauma. Fluent aphasia was more common in both groups alike. In aphasia subcategories, however, transcortical sensory aphasia (TSA) in operative and anomia in nonoperative group were the most prevalent. Several variables appeared strikingly related to higher aphasia in operative groups as follows: moderate to severe injury, 18-35 and over 50 years of age, more than 1 week PTA, intracranial surgery of multiple lesions in left or bilateral hemisphere fronto-temporal cortex plus post-trauma cognitive and pragmatic impairments, and diffuse axonal injuries. DISCUSSION Almost certainly, meaningful drop of cognitive function post surgery roots back in significant loss of initial consciousness level. Related factors to postoperative aphasia suggest taking policies through surgery intervention. Discerning the indispensable contributions of neurosurgeons, neurolinguists, and neuroscientists, results inspire more clinical future studies.
Collapse
|
42
|
Huang YH, Deng YH, Lee TC, Chen WF. Rotterdam Computed Tomography Score as a Prognosticator in Head-Injured Patients Undergoing Decompressive Craniectomy. Neurosurgery 2012; 71:80-5. [DOI: 10.1227/neu.0b013e3182517aa1] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The Rotterdam computed tomography (CT) score was developed for prognostic purposes in traumatic brain injury (TBI).
OBJECTIVE:
To examine the prognostic discrimination and prediction of the Rotterdam CT score in the case of patients undergoing decompressive craniectomy (DC) for TBI.
METHODS:
The CT scans with the worst findings before DC were scored according to the Rotterdam CT classification. Mortality and Glasgow Outcome Scale score at the end of follow-up were used as outcome measures. Unfavorable and favorable outcomes were defined by a Glasgow Outcome Scale score of 1 to 3 and 4 to 5, respectively. We used binary logistic and proportional odds regression for prognostic analyses.
RESULTS:
The relationship between the Rotterdam CT score and prognosis was quantified, and higher scores indicated worse patient outcomes. Univariate analysis showed that the Rotterdam CT score was significantly associated with mortality (odds ratio: 3.117, 95% confidence interval: 1.867-5.386; P < .001) and unfavorable outcomes (odds ratio: 2.612, 95% confidence interval: 1.733-3.939; P < .001). After adjustment for published outcome predictors of TBI in multivariate regression, the Rotterdam CT score remained an independent predictor of unfavorable outcomes (odds ratio: 1.830, 95% confidence interval: 1.043-3.212; P = .035).
CONCLUSION:
For head-injured patients undergoing DC, the Rotterdam CT score provides great prognostic discrimination and is an independent predictor of unfavorable outcomes. We suggest that the Rotterdam CT score be included as a prognosticator in the overall assessment of clinical condition of TBI patients before DC.
Collapse
Affiliation(s)
- Yu-Hua Huang
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Han Deng
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tao-Chen Lee
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wu-Fu Chen
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| |
Collapse
|
43
|
Comparison of Craniotomy and Decompressive Craniectomy in Severely Head-Injured Patients With Acute Subdural Hematoma. ACTA ACUST UNITED AC 2011; 71:1632-6. [DOI: 10.1097/ta.0b013e3182367b3c] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
44
|
Kuo JR, Lo CJ, Lu CL, Chio CC, Wang CC, Lin KC. Prognostic predictors of outcome in an operative series in traumatic brain injury patients. J Formos Med Assoc 2011; 110:258-64. [PMID: 21540008 DOI: 10.1016/s0929-6646(11)60038-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 11/13/2009] [Accepted: 04/28/2010] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Although several prognostic factors for traumatic brain injury (TBI) have been evaluated, a useful predictive scoring model for outcome has yet to be developed for TBI patients. The aim of this study was to determine independent predictors and develop a multivariate logistic regression equation to determine prognosis in TBI patients. METHODS A total of 13 different variables were evaluated. All 84 patients in this study were retrospectively evaluated between October 2003 and January 2008 and all underwent craniectomy or craniotomy for hematoma removal and were fitted with intracranial pressure (ICP) microsensor monitors. By using univariate, multiple logistic regression and prognostic regression scoring equations it was possible to draw Receiver-Operating Characteristic curves (ROC) to predict Glasgow Outcome Scale (GOS) 6 months after TBI. RESULTS We found that patients over 40 years of age (p < 0.001), unresponsive pre-op pupil reaction (p =0.001), pre-op midline shift (p =0.008), higher injury severity score (ISS; p=0.007), and craniectomy (p < 0.05) were associated with poor outcome in patients with TBI. Using ROC curve to predict the probability of unfavorable outcome, the sensitivity was 97.5% and the specificity was 90.7%. CONCLUSION In our preliminary findings, five variables to predict poor outcomes 6 months after TBI were useful. These sensitive variables can be used as a referential guideline in our daily practice to decide whether or not to perform advanced management or avoid decompressive craniectomy.
Collapse
Affiliation(s)
- Jinn-Rung Kuo
- Institute of Clinical Medicine, School of Medicine, National Cheng-Kung University, Southern Taiwan University, Tainan, Taiwan
| | | | | | | | | | | |
Collapse
|
45
|
Decompressive Craniectomy for Diffuse Cerebral Swelling After Trauma: Long-Term Outcome and Ethical Considerations. ACTA ACUST UNITED AC 2011; 71:128-32. [DOI: 10.1097/ta.0b013e3182117b6c] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
46
|
Rogers SJ, Browne AL, Vidovich M, Honeybul S. Defining meaningful outcomes after decompressive craniectomy for traumatic brain injury: Existing challenges and future targets. Brain Inj 2011; 25:651-63. [DOI: 10.3109/02699052.2011.580316] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
47
|
Honeybul S, Ho KM, Lind CRP, Gillett GR. Surgical intervention for severe head injury: ethical considerations when performing life-saving but non-restorative surgery. Acta Neurochir (Wien) 2011; 153:1105-10. [PMID: 21347576 DOI: 10.1007/s00701-011-0974-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 02/10/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this study was to compare the predicted outcome with observed outcome in those patients who have had a unilateral decompressive craniectomy following evacuation of an intracranial mass lesion and to consider some of the ethical issues that need to be addressed when performing life-saving but non-restorative surgery. METHODS By using the web-based outcome prediction model developed by the CRASH trial collaborators predicted and observed outcomes were compared for those patients who had had a unilateral decompression after evacuation of a mass lesion in the two major neurotrauma hospitals in Western Australia between 2004 and 2008. Three cases were selected with differing outcome predictions. RESULTS For the three selected cases the predicted risk of an unfavourable outcome at 6 months was 65.8%, 78.9% and 91.3%, respectively. For the 11 patients in this cohort with an outcome prediction between 61% and 70%, the observed outcome at 18 months (GOS) was: 5 had a good outcome, 4 were moderately disabled, and 3 were severely disabled. For the ten patients with an outcome prediction between 90-100%, observed outcome confirmed: one patient was moderately disabled, four patients were severely disabled, one patient was in a permanent vegetative state, and four patients had died. CONCLUSION As the index of injury severity (as adjudged by the CRASH outcome prediction model) increases, clinical decision making and discussion with surrogates must reflect the evidence provided by observed outcome, prior to life-saving but potentially non-restorative decompressive surgery.
Collapse
|
48
|
Intiso D, Lombardi T, Grimaldi G, Iarossi A, Tolfa M, Russo M, Di Rienzo F. Long-term outcome and health status in decompressive craniectomized patients with intractable intracranial pressure after severe brain injury. Brain Inj 2011; 25:379-86. [DOI: 10.3109/02699052.2011.558046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
49
|
Honeybul S, O'Hanlon S, Ho KM. Decompressive Craniectomy for Severe Head Injury: Does an Outcome Prediction Model Influence Clinical Decision-Making? J Neurotrauma 2011; 28:13-9. [DOI: 10.1089/neu.2010.1584] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Perth, Western Australia, Australia
| | - Susan O'Hanlon
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Perth, Western Australia, Australia
| | - Kwok M. Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
50
|
|