Decompressive craniectomy for traumatic brain injury: patient age and outcome

Baseline Characteristics Associated with Improved Outcomes in Patients Undergoing Primary Decompressive Craniectomy for Acute Subdural Hematoma Evacuation-A Retrospective Observational Study

Background and Objective: The study's aim is to identify a subgroup of patients who would benefit from primary decompressive craniectomy (pDC) after acute subdural hematoma (aSDH) evacuation. Materials and Methods: A retrospective analysis of 290 patients undergoing aSDH evacuation between 2016 and 2021 was conducted. Osteoplastic craniotomy (OC) was performed in 213 cases (73.4%), whereas 77 individuals underwent pDC. Preoperative characteristics, such as age, initial GCS score, hematoma thickness, midline shift, and cisternal effacement score (CES), were used to predict outcome at discharge by the Glasgow Outcome Scale (GOS). Results: Older age, lower initial GCS, and higher CES preoperatively were independently associated with lower GOS scores at discharge. Age and degree of cisternal compression remained significant predictors of GOS score in the pDC subgroup. Survivors who underwent pDC were younger in comparison to deceased individuals receiving OC (mean age 55.43 ± 14.58 vs. 72.28 ± 14.63, p < 0.001). Patients who achieved favorable outcomes after pDC were significantly younger compared to those who had poor outcomes after OC (mean age 49.20 ± 12.05 vs. 72.28 ± 14.32, p < 0.001). Conclusions: Younger patients (<55 years old) with initial GCS scores of 4-6, midline shifts of 1 to 2 cm, subdural hematoma thickness of 1 to 2.5 cm, and CES in a range of 7-12 may benefit from pDC as it could potentially improve survival and functional outcomes after aSDH evacuation.

Intracranial pressure changes in traumatic brain injury patients undergoing unilateral decompressive craniectomy with dural expansion

Background

The aim of this study is to assess the ICP changes induced by a unilateral fronto-temporo-parietal DC with dural expansion after moderate to severe TBI. The effect of different bone flap sizes on ICP and the neurological outcomes were also evaluated after the decompressive surgery.

Methods

52 TBI patients with clinical and radiological evidences of increased ICP were included in this prospective study. All patients received unilateral fronto-temporo-parietal DC with dural expansion and ventriculostomy at contralateral Kocher's point. Postoperatively, ICP values and the largest antero-posterior (AP) diameter of bone flap removed was measured, and the clinical outcomes were assessed using Extended Glasgow Outcome Scale (GOS-E) at discharge and 6 months after DC.

Results

The median ICP significantly decreased with an average of 56.7 % reduction from the initial opening ICP. Similar ICP changes were observed in all groups. This study also found that the large bone flap group (AP diameter >15 cm) demonstrated better postoperative ICP control as compared to the small bone flap group (AP diameter 12-15 cm), although not statistically significant. The SDH and cerebral swelling groups did better in the GOS-E at 6 months after TBI compared with cerebral contusion group.

Conclusion

The ICP reduction in moderate to severe TBI patients undergoing unilateral fronto-temporo-parietal DC with dural expansion occurred in accordance with decompressive steps, regardless of intracranial lesions and the surgical procedure should be performed with the bone flap size of at least 12 cm in AP diameter for adequate and sustained ICP control.

Neurosurgical intervention in ultra-severe closed traumatic brain injury: Is it worth the effort?

Introduction

A subgroup of severe Traumatic Brain Injury (TBI) patients, known as ultra-severe (us-TBI), is most commonly defined as a post-resuscitation Glasgow Coma Scale (GCS) of 3-5. There is uncertainty on whether these critically injured patients can benefit from neurosurgical intervention.

Research question

The available evidence regarding the decision-making and outcome following management of us-TBI patients is critically reviewed.

Material and methods

Selected databases (PubMed, Google Scholar, Scopus and Cochrane Library) were searched from 1979 to May 2024 for publications on us-TBI patients, with a focus on treatment strategy, mortality and functional outcomes. Inclusion criteria were adult patients >18 years old with closed head trauma and admission post-resuscitation GCS 3-5. Studies were independently assessed for inclusion by two reviewers, and potential disagreements were solved by consensus.

Results

Where such data could be extracted, mortality rate was 27-100%, and favorable outcome was observed in 4-30% of us-TBI patients. While early aggressive neurosurgical management was associated with decreased mortality, a high proportion of patients survived with unfavorable functional status.

Discussion and conclusion

With supportive care only, outcome of patients with us-TBI is almost universally poor. Early and aggressive neurosurgical intervention in addition to best medical management can lead to favorable functional outcome in selected cases particularly in younger patients with an initial GCS>3 and traumatic mass lesions. There is insufficient data regarding the effectiveness of neurosurgical management on the outcome of us-TBI patients. and the decision to initiate treatment should be based on an individual basis.

Outcome after decompressive craniectomy in older adults after traumatic brain injury

Objective

Globally, many societies are experiencing an increase in the number of older adults (>65 years). However, there has been a widening gap between the chronological and biological age of older adults which trend to a more active and social participating part of the society. Concurrently, the incidence of traumatic brain injury (TBI) is increasing globally. The aim of this study was to investigate the outcome after TBI and decompressive craniectomy (DC) in older adults compared with younger patients.

Methods

A retrospective, multi-centre, descriptive, observational study was conducted, including severe TBI patients who were treated with DC between 2005 and 2022. Outcome after discharge and 12 months was evaluated according to the Glasgow Outcome Scale (Sliding dichotomy based on three prognostic bands). Significance was established as p ≤ 0.05.

Results

A total of 223 patients were included. The majority (N = 158, 70.9%) survived TBI and DC at discharge. However, unfavourable outcome was predominant at discharge (88%) and after 12 months (67%). There was a difference in favour of younger patients (≤65 years) between the age groups at discharge (p = 0.006) and at 12 months (p < 0.001). A subgroup analysis of the older patients (66 to ≤74 vs. ≥75 years) did not reveal any significant differences. After 12 months, 64% of the older patients had a fatal outcome. Only 10% of those >65 years old had a good or very good outcome. 25% were depending on support in everyday activities. After 12 months, the age (OR 0.937, p = 0.007, CI 95%: 0.894-0.981; univariate) and performed cranioplasty (univariate and multivariate results) were influential factors for the dichotomized GOS. For unfavourable outcome after 12 months, the thresholds were calculated for age = 55.5 years (p < 0.001), time between trauma and surgery = 8.25 h (p = 0.671) and Glasgow Coma Scale (GCS) = 4 (p = 0.429).

Conclusion

Even under the current modern conditions of neuro-critical care, with significant advances in intensive care and rehabilitation medicine, the majority of patients >65 years of age following severe TBI and DC died or were dependent and usually required extensive support. This aspect should also be taken into account during decision making and counselling (inter-, intradisciplinary or with relatives) for a very mobile and active older section of society, together with the patient's will.

Non-pharmacological interventions for traumatic brain injury

Heterogeneity and variability of symptoms due to the type, site, age, sex, and severity of injury make each case of traumatic brain injury (TBI) unique. Considering this, a universal treatment strategy may not be fruitful in managing outcomes after TBI. Most of the pharmacological therapies for TBI aim at modifying a particular pathway or molecular process in the sequelae of secondary injury rather than a holistic approach. On the other hand, non-pharmacological interventions such as hypothermia, hyperbaric oxygen, preconditioning with dietary adaptations, exercise, environmental enrichment, deep brain stimulation, decompressive craniectomy, probiotic use, gene therapy, music therapy, and stem cell therapy can promote healing by modulating multiple neuroprotective mechanisms. In this review, we discussed the major non-pharmacological interventions that are being tested in animal models of TBI as well as in clinical trials. We evaluated the functional outcomes of various interventions with an emphasis on the links between molecular mechanisms and outcomes after TBI.

Prognostic variables predict clinical outcome after decompressive craniectomy: A single institute experience; A retrospective study

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.

Novel CT-based parameters assessing relative cross-sectional area to guide surgical management and predict clinical outcomes in patients with acute subdural hematoma

INTRODUCTION

Acute subdural hematoma (aSDH) is one of the most devastating entities secondary to traumatic brain injury (TBI). Even though radiological computed tomography (CT) findings, such as hematoma thickness (HT), midline shift (MLS), and MLS/HT ratio, have an important prognostic role, they suffer from important drawbacks. We hypothesized that relative cross-sectional area (rCSA) of specific brain regions would provide valuable information about brain compression and swelling, thus being a key determining factor governing the clinical course.

METHODS

We performed an 8-year retrospective analysis of patients with moderate to severe TBI with surgically evacuated, isolated, unilateral aSDH. We investigated the influence of aSDH rCSA and ipsilateral hemisphere rCSA along the supratentorial region on the subsequent operative technique employed for aSDH evacuation and patient's clinical outcomes (early death and Glasgow Outcome Scale [GOS] at discharge and after 1-year follow-up). Different conventional radiological variables were also assessed.

RESULTS

The study included 39 patients. Lower HT, MLS, hematoma volume, and aSDH rCSA showed a significant association with decompressive craniectomy (DC) procedure. Conversely, higher ipsilateral hemisphere rCSA along the dorso-ventral axis and, specifically, ipsilateral hemisphere rCSA at the high convexity level were predictors for DC. CT segmentation analysis exhibited a modest relationship with early death, which was limited to the basal supratentorial subregion, but could not predict long-term outcome.

CONCLUSION

rCSA is an objectifiable and reliable radiologic parameter available on admission CT that might provide valuable information to optimize surgical treatment.

Ethical Considerations in Surgical Decompression for Stroke

Stroke is a major cause of morbidity and mortality. Neurosurgical decompression is often considered for the treatment of malignant infarcts and intraparenchymal hemorrhages, but this treatment can be frought with ethical dilemmas. In this article, the authors outline the primary principles of bioethics and their application to stroke care, provide an overview of key ethical issues and special situations in the neurosurgical management of stroke, and highlight methods to improve ethical decision-making for patients with stroke. Understanding these ethical principles is essential for stroke care teams to deliver appropriate, timely, and ethical care to patients with stroke.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Craniotomy size for traumatic acute subdural hematomas in elderly patients-same procedure for every age?

Surgical treatment of acute subdural hematoma (aSDH) is still matter of debate, especially in the elderly. A retrospective study to compare two different surgical approaches, namely standard (SC, craniotomy size > 8 cm) and limited craniotomy (LC, craniotomy size < 8 cm), was conducted in elderly patients with traumatic aSDH to identify the role of craniotomy size in terms of clinical and radiological outcome. Sixty-four patients aged 75 or older with aSDH as sole lesion were retrospectively analyzed. Data were collected pre- and postoperatively including clinical and radiological criteria. The primary outcome parameter was 30-day mortality. Secondary outcome parameters were radiological. The mean age was 79.2 (± 3.1) years with no difference between groups and almost equal distribution of craniotomy size. Mortality rate was significantly higher in the SC group in comparison to the LC group (68.4% vs. 31.6%; p = 0.045). The preoperative HD (p = 0.08) and the MLS (p = 0.09) were significantly higher in the SC group, whereas postoperative radiological evaluation showed no significant difference in HD or MLS. A limited craniotomy is sufficient for adequate evacuation of an aSDH in the elderly achieving the same radiological and clinical outcome.

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

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

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

BACKGROUND

High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy).

OBJECTIVES

To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP.

SEARCH METHODS

The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts.

SELECTION CRITERIA

We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care.

DATA COLLECTION AND ANALYSIS

We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach.

MAIN RESULTS

We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events.

AUTHORS' CONCLUSIONS

Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.

Operative versus non-operative treatment of traumatic brain injuries in patients 80 years of age or older

Traumatic brain injury (TBI) in older adults is an increasing issue in modern medicine. Nevertheless, it remains unclear which patients presenting with TBI and 80 years of age or older benefit from an operative treatment. The aim of this study was to explore the effect of an operative treatment in isolated TBI patients ≥ 80 years of age. Data were derived from the TraumaRegister DGU^® from 2002 to 2016. Inclusion criteria were ≥ 80 years of age, an Abbreviated Injury Scale_Head (AIS) ≥ 3, and an AIS_Non-Head ≤ 1. The cohort was split in operatively and non-operatively treated patients, and outcome was assessed at discharge using the Glasgow Outcome Scale (GOS). A favorable outcome was defined as a GOS of 4 or 5. A total of 1.693 patients (431 operatively and 1.262 non-operatively treated patients) were analyzed. Mortality rate was 54.4% (687 patients) in the non-operative group and 49.4% in the operative group. Simultaneously, there were more patients discharged with a GOS 2 (persistent vegetative state) in the operative group (7.9%, 34 patients) than in the non-operative group (1.0%, 13 patients). An analysis of the operatively treated patients showed an association between a higher mortality risk and brainstem hemorrhage (p = 0.04), fixed pupils (p = 0.001), initial intubation (p = 0.03), and an AIS_Head of 5/6 (p = 0.03). Patients 80 years of age or older seem to benefit from an operative treatment regarding mortality rate. However, there has been a higher rate of a poor neurological outcome particularly with regard to persistent vegetative state in the operative treatment group at discharge.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk factors predicting prognosis and outcome of elderly patients with isolated traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI), particularly in the elderly patient population, is known to be the single largest cause of death and disability worldwide. The purpose of this retrospective study was to evaluate clinical factors predicting poor outcome with special emphasis on the impact of respiratory failure (RF) on mortality in elderly patients with isolated severe TBI.

METHODS

All elderly patients (age ≥ 65 years) with isolated severe head injury, admitted to this level I trauma center, during a period of 18 years (from January 1992 to December 2010) were identified from the trauma registry. The medical records were reviewed for demographics, mechanism of injury (MOI), GCS score at admission, RF, pupillary light reflex (LR), CT findings (subdural hematoma, subarachnoid hematoma, edema, midline-shift), and whether there was conservative treatment or surgical intervention and the Glasgow Outcome Score (GOS) at hospital discharge. Stepwise logistic regression analysis was used to identify risk factors for a poor prognosis and outcome.

RESULTS

The following variables influenced the mortality: respiratory failure, pupillary response, and the injury severity score (ISS). A significant increased risk of death was also found for patients with a midline shift of over 15 mm.

CONCLUSIONS

The present study predicts a strong correlation between respiratory failure, pathological pupillary response, a higher ISS, and substantial midline shift with poor outcomes in elderly patients sustaining an isolated severe TBI.

TRIAL REGISTRATION

Clinical trials: ID: NCT02386865 . Registered 12 March 2015-retrospectively registered.

Early and late clinical outcomes after decompressive craniectomy for traumatic refractory intracranial hypertension: a systematic review and meta-analysis of current evidence

INTRODUCTION

Decompressive craniectomy (DC) to control refractory intracranial hypertension in patients with traumatic brain injury (TBI), has been listed as possible but controversial therapeutic approach in the latest version of TBI management guidelines. This study aimed to perform a systematic review and meta-analysis on efficacy and safety of DC compared to standard care in TBI patients.

EVIDENCE ACQUISITION

A database search from 2011 to 2017 was conducted to identify studies pertinent to DC compared to standard care after TBI. The primary outcomes were mortality and functional outcome upon hospital discharge and at 6 and 12 months after intervention, whereas secondary outcomes were intracranial pressure (ICP) control, hospitalization data and occurrence of adverse events.

EVIDENCE SYNTHESIS

Three randomized controlled trials and two observational studies enrolling 3451 patients were selected for qualitative analysis, among which four were included in the meta-analysis. DC-treated patients showed a significant reduction of overall mortality (RR, 0.57; 95% CI: 0.5-0.66; P<0.001; I2=17%) with no profound beneficial effect on functional outcome (RR, 0.89; 95% CI: 0.78-1.02; P=0.09; I2=58%) compared to those receiving standard care. A more efficient ICP reduction and a tendency towards shorter duration of hospitalization were recorded in DC versus standard care group. Adverse events are more common in DC-treated patients.

CONCLUSIONS

It seems that, in TBI patients with intracranial hypertension, the use of DC is associated with survival benefit when compared to medical therapy alone, but with no clear improvement of functional outcome. Yet no definite conclusion can be drawn due to limited quantity and considerable heterogeneity of available data.

Fourteen-Day Mortality in Pediatric Patients with Traumatic Brain Injury After Early Decompressive Craniectomy: A Single-Center Retrospective Study

OBJECTIVE

The purpose of this study was to analyze the risk factors for 14-day mortality in pediatric patients undergoing early decompressive craniectomy (DC) after traumatic brain injury (TBI).

METHODS

This retrospective analysis included all pediatric patients (≤16 years of age) undergoing DC within 12 hours of TBI between August 2011 and July 2017 at the authors' institute. Demographic information, clinical characteristics, surgical information, and laboratory parameters were retrieved from medical records. Risk factors for 14-day mortality were analyzed using multivariate logistic regression models. First, potentially relevant variables were compared between those who died within 14 days versus those who did not. Variables with P < 0.10 were entered into the final multivariate regression analysis.

RESULTS

A total of 36 patients (23 boys and 13 girls; median age, 7 years) were included in the analysis. Fall (n = 19, 52.8%) was the leading cause of injury. The 14-day mortality was 38.9% (14/36). At the time of admission, the median Glasgow Score Scale (GCS) was 6 (IQR 4-8), and the mean Injury Severity Score (ISS) (± standard deviation) was 29.03 ± 8.54. Preoperative hypoxia, defined as oxyhemoglobin arterial saturation <90% or apnea >20 seconds, was observed in 6 patients (16.7%). Coagulopathy was present in 14 patients (38.9%). Multivariate logistic regression analysis suggested an association between 14-day mortality and younger age (odds ratio [OR] = 0.708, 95% confidence interval [CI]: 0.513-0.978; P = 0.036) and higher ISS (OR = 1.399; 95% CI: 1.023-1.914; P = 0.035).

CONCLUSIONS

In children undergoing early DC after TBI, risk factors for 14-day mortality include younger age and higher ISS.

Craniectomy and Craniotomy in Traumatic Brain Injury: A Propensity-Matched Analysis of Long-Term Functional and Quality of Life Outcomes

OBJECTIVE

To report the comprehensive long-term functional and quality of life outcomes after craniectomy (CE) and craniotomy (CO) in individuals with traumatic brain injury (TBI).

METHODS

Information on all individuals with TBI who had undergone CE or CO were extracted from the TBI Model Systems database from 2002 to 2012. A 1:1 propensity matching with replacement technique was used to balance the baseline characteristics across groups. The matched sample was analyzed for outcomes during hospitalization, acute rehabilitation, and ≤2 years of follow-up.

RESULTS

We identified 1470 individuals who had undergone CE or CO. Individuals undergoing CE compared with CO demonstrated a longer length of stay in the hospital (median, 22 vs. 18 days; P < 0.0001) and acute rehabilitation (median 26 vs. 21 days; P < 0.0001). Individuals with CE had required rehospitalization more often by the 1-year follow-up point (39% vs. 25%; P < 0.0001) for reasons other than cranioplasty, including seizures (12% vs. 8%; P < 0.0001), neurologic events (i.e., hydrocephalus; 9% vs. 4%; P < 0.0001), and infections (10% vs 6%; P < 0.0001). Individuals with CE had significantly greater impairment using the Glasgow Outcome Scale-Extended, required more supervision, and were less likely to be employed at 1 and 2 years after TBI. No difference was observed in the satisfaction with life scale scores at 2 years. The Kaplan-Meier mortality estimates at 1 and 2 years showed no differences between the 2 groups (hazard ratio, 0.57; P = 0.4).

CONCLUSION

In a matched cohort, individuals undergoing CE compared with CO after TBI had a longer length of stay, decreased functional status, and more rehospitalizations. The survival at 2 years and the satisfaction with life scale scores were similar.

Factors Affecting Functional Outcome after Decompressive Craniectomy Performed for Traumatic Brain Injury: A Retrospective, Cross-sectional Study

Background:

Factors affecting functional outcome after decompressive craniectomy (DC) performed for traumatic brain injury (TBI) remain poorly understood.

Methods:

We conducted a retrospective study of all patients who underwent primary DC for TBI at our hospital between 2010 and 2014. Multivariate regression analyses were used to determine the predictors of functional outcome and overall survival.

Results:

A total of 98 patients with severe (n = 81, 82.6%) or moderate (n = 17, 17.4%) TBI underwent primary DC and were included in this study. The 30-day and overall mortality rates were 15.3% and 25.5%, respectively. At a median follow-up of 90 (interquartile range (IQR): 38–180) days, median Karnofsky Performance Status (KPS) and Glasgow outcome scale-extended (GOSE) scores were 50 (IQR: 20–70) and 5 (IQR: 3–7), respectively. Young age and severe TBI were predictors of mortality. Glasgow coma scale (GCS) score on discharge was a strong predictor of KPS and GOSE scores.

Conclusion:

Primary DC afforded an acceptable functional outcome (GOSE score ≥5) in 45.9% of patients. Young age and lower GCS at presentation were associated with worse survival. GCS score on discharge was a strong predictor of functional outcome.

Risk factors for intracranial lesions and mortality in older patients with mild traumatic brain injuries

PRIMARY OBJECTIVE

To identify risk factors for intracerebral lesion (ICL) in older adults with mild traumatic brain injury (MTBI) and evaluate the influence of comorbidities on outcomes.

RESEARCH DESIGN

Prospective cohort study.

METHODS AND PROCEDURES

Information was gathered on clinical history/examination, cranial computed tomography, admission Glasgow Coma Scale (GCS) score, analytical and coagulation findings, and mortality at 1 week post-discharge. Bivariate and multivariate logistic regression analyses were performed, calculating odds ratios for ICL with 95% confidence interval. P < 0.05 was considered significant.

MAIN OUTCOMES AND RESULTS

Data were analyzed on 504 patients with mean±SD age of 79.37 ± 8.06 years. Multivariate analysis showed that traffic accident, GCS score of 14/15, transient consciousness loss, nausea, and receipt of antiplatelets were predictors of ICL, while SRRI and/or benzodiazepine intake was a protective factor. A score was assigned to patients by rounding OR values, and a score ≥1 indicated moderate/high risk of ICL.

CONCLUSIONS

MTBI management should be distinct in over-60 year-olds, who may not present typical symptoms, with frequent comorbidities. Knowledge of risk factors for post-MTBI ICL, associated with higher mortality, is important to support clinical decision-making. Further research is warranted to verify our novel finding that benzodiazepines and/or SSRI inhibitors may act as neuroprotectors.

Outcome after operative intervention for traumatic brain injuries in the elderly

INTRODUCTION

The management of traumatic brain injuries in the elderly (age ≥ 65 years) is a constant dilemma. The aim of this study is to investigate for factors that may predict outcome of operative treatment in this group of patients.

MATERIALS AND METHODS

A retrospective analysis was conducted on 68 elderly patients who had been operated in a designated center from 2006 to 2010. Patients' age, Glasgow Coma score (GCS), pupillary responses, imaging findings, medical conditions, and the use of anticoagulant/antiplatelet agents on patient outcomes were studied.

RESULTS

The overall mortality rate was 55.9%. Older age, abnormal pupillary response, low GCS, the presence of midline shift and cistern obliteration on computerized tomography were associated with poor survival. Patient aged 75-84 with normal bilateral pupillary response still had an overall survival rate of 52.6% and good outcomes (Glasgow outcome score: 4 or 5) in 36.8% of patients. Abnormal pupillary response in at least one eye and preoperative GCS ≤ 12 were associated with very poor prognosis.

CONCLUSIONS

More advanced age was found to be associated with progressively worse outcome. A subgroup patients aged below 85 would survive and could achieve good clinical outcome. The prognosis of those aged over 85 with moderate or severe head injuries was extremely poor.

The Role of Magnetic Resonance Imaging in the Prediction of Minimally Conscious State After Traumatic Brain Injury

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.

Prospective randomized evaluation of therapeutic decompressive craniectomy in severe traumatic brain injury with mass lesions (PRECIS): study protocol for a controlled trial

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.

New Radiologic Parameters Predict Clinical Outcome after Decompressive Craniectomy

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.

Radiological prognostication in patients with head trauma requiring decompressive craniectomy: Analysis of optic nerve sheath diameter and Rotterdam CT Scoring System

INTRODUCTION

Optic nerve sheath diameter (ONSD) measured on CT scan has been shown to predict outcomes of patients with severe traumatic brain injury. No such relation has been studied in patients undergoing decompressive craniectomy (DC). We evaluated ONSD on admission CT scan to predict outcomes of patients undergoing DC along with Rotterdam CT Score (RCTS).

MATERIALS AND METHODS

This retrospective cohort study was approved by the institutional ethics committee. All the consecutive patients undergoing DC with available images and records were included. We measured ONSD 3mm behind the eyeball and calculated RCTS. Glasgow Outcome Scale (GOS) was measured at last follow-up. We analyzed the data on SPSS v 19. Receiver operator curve analysis (ROC) was done to measure the predictive values of ONSD and RCTS for mortality and unfavorable outcomes.

RESULTS

One hundred and seventeen patients were included. Twenty patients had bilateral DC. Mean GCS at presentation was 8.5±3.5. Mean follow-up was 7.5±1.2 months. Thirty-day mortality was 19%. Mean ONSD of both eyes was 6.73±0.89mm. Area under the curve (AUC) for bilateral mean ONSD as predictor of mortality was 0.49 [95%CI: 0.36-0.62]. AUC for RCTS was as a predictor of 30-day mortality was significant, i.e. 0.67 [95%CI: 0.572-0.820]. The difference of mean ONSD was also not significantly different between survivor and non-survivors.

CONCLUSION

Admission ONSD in DC patients is high but does not predict mortality and unfavorable outcomes. RCTS has a better prognostic value for predicting mortality and unfavorable outcomes in DC patients.

Aggressive operative treatment of isolated blunt traumatic brain injury in the elderly is associated with favourable outcome

Outcome after traumatic brain injury (TBI) in the elderly has not been fully elucidated. The present retrospective observational study investigates the age-dependent outcome of patients suffering from severe isolated TBI with regard to operative and non-operative treatment. Data were prospectively collected in the TraumaRegister DGU. Anonymous datasets of 8629 patients with isolated severe blunt TBI (AISHead≥3, AISBody≤1) documented from 2002 to 2011 were analysed. Patients were grouped according to age: 1-17, 18-59, 60-69, 70-79 and ≥80 years. Cranial fractures (44.8%) and subdural haematomas (42.6%) were the most common TBIs. Independent from the type of TBI the group of patients with operative treatment declined with rising age. Subgroup analysis of patients with critical TBI (AISHead=5) revealed standardised mortality ratios (SMRs) of 0.81 (95% CI 0.75-0.87) in case of operative treatment (n=1201) and 1.13 (95% CI 1.09-1.18) in case of non-operative treatment (n=1096). All age groups ≥60 years showed significantly reduced SMRs in case of operative treatment. Across all age groups the group of patients with low/moderate disability according to the GOS (4 or 5 points) was higher in case of operative treatment. Results of this retrospective observational study have to be interpreted cautiously. However, good outcome after TBI with severe space-occupying haemorrhage is more frequent in patients with operative treatment across all age groups. Age alone should not be the reason for limited care or denial of operative intervention.

Options for managing raised intracranial pressure

This article reviews the current monitoring and management options for raised intracranial pressure (ICP), primarily in traumatic head injuries, in line with current literature and guidelines. The use of ICP monitoring is useful in managing, predicting outcomes, following the progression and guiding interventions of neurological disease states.

Patients with raised ICP should be monitored closely in a neurocritical care setting where appropriate interventions can be instituted based on available monitoring parameters. Various first- and second-tier methods should be considered, with the primary goal to decrease secondary insult to brain tissue for best outcomes.

Primary or Secondary Decompressive Craniectomy: Different Indication and Outcome

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.

Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis

BACKGROUND

Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH.

METHODS

Eleven Level 1 trauma centers provided clinical data and head computed tomographic scans for patients with a Glasgow Coma Scale (GCS) score of 13 or less and radiographic evidence of TBI excluding deaths within 48 hours. Computed tomographic scans were graded according to the Marshall classification. A propensity score to receive DC (regardless of whether DC was performed) was calculated for each patient based on patient characteristics, physiology, injury severity, GCS, severity of intracranial injury, and treatment center. Patients who actually received a DC were matched to patients with similar propensity scores who received MT for analysis. Outcomes were compared between early (<48 hours of injury) primary or secondary DC and matched controls and then between early primary DC only and matched controls.

RESULTS

There were 2,602 patients who met the inclusion criteria ,of whom 264 (10.1%) received DC (either primary or secondary to another cranial procedure) and 109 (5%) had a DC that was primary. Variables associated with performing a DC included sex, race, intracranial pressure monitor placement, in-house trauma attending, traumatic subarachnoid hemorrhage, midline shift, and basal cistern compression. There was no survival benefit with early primary DC compared with the controls (relative risk, 1.07; 95% confidence interval, 0.67-1.73; p = 0.77), and resource use was higher.

CONCLUSION

Early DC does not seem to significantly improve mortality in patients with refractory ICH compared with MT. Neurosurgeons should pause before entertaining this resource-demanding form of therapy.

LEVEL OF EVIDENCE

Therapeutic care/management, level III.

Surgical management of traumatic brain injury: a comparative-effectiveness study of 2 centers

Object

Mass lesions from traumatic brain injury (TBI) often require surgical evacuation as a life-saving measure and to improve outcomes, but optimal timing and surgical technique, including decompressive craniectomy, have not been fully defined. The authors compared neurosurgical approaches in the treatment of TBI at 2 academic medical centers to document variations in real-world practice and evaluate the efficacies of different approaches on postsurgical course and long-term outcome.

Methods

Patients 18 years of age or older who required neurosurgical lesion evacuation or decompression for TBI were enrolled in the Co-Operative Studies on Brain Injury Depolarizations (COSBID) at King's College Hospital (KCH, n = 27) and Virginia Commonwealth University (VCU, n = 24) from July 2004 to March 2010. Subdural electrode strips were placed at the time of surgery for subsequent electrocorticographic monitoring of spreading depolarizations; injury characteristics, physiological monitoring data, and 6-month outcomes were collected prospectively. CT scans and medical records were reviewed retrospectively to determine lesion characteristics, surgical indications, and procedures performed.

Results

Patients enrolled at KCH were significantly older than those enrolled at VCU (48 vs 34 years, p < 0.01) and falls were more commonly the cause of TBI in the KCH group than in the VCU group. Otherwise, KCH and VCU patients had similar prognoses, lesion types (subdural hematomas: 30%–35%; parenchymal contusions: 48%–52%), signs of mass effect (midline shift ≥ 5 mm: 43%–52%), and preoperative intracranial pressure (ICP). At VCU, however, surgeries were performed earlier (median 0.51 vs 0.83 days posttrauma, p < 0.05), bone flaps were larger (mean 82 vs 53 cm2, p < 0.001), and craniectomies were more common (performed in 75% vs 44% of cases, p < 0.05). Postoperatively, maximum ICP values were lower at VCU (mean 22.5 vs 31.4 mm Hg, p < 0.01). Differences in incidence of spreading depolarizations (KCH: 63%, VCU: 42%, p = 0.13) and poor outcomes (KCH: 54%, VCU: 33%, p = 0.14) were not significant. In a subgroup analysis of only those patients who underwent early (< 24 hours) lesion evacuation (KCH: n = 14; VCU: n = 16), however, VCU patients fared significantly better. In the VCU patients, bone flaps were larger (mean 85 vs 48 cm2 at KCH, p < 0.001), spreading depolarizations were less common (31% vs 86% at KCH, p < 0.01), postoperative ICP values were lower (mean: 20.8 vs 30.2 mm Hg at KCH, p < 0.05), and good outcomes were more common (69% vs 29% at KCH, p < 0.05). Spreading depolarizations were the only significant predictor of outcome in multivariate analysis.

Conclusions

This comparative-effectiveness study provides evidence for major practice variation in surgical management of severe TBI. Although ages differed between the 2 cohorts, the results suggest that a more aggressive approach, including earlier surgery, larger craniotomy, and removal of bone flap, may reduce ICP, prevent cortical spreading depolarizations, and improve outcomes. In particular, patients requiring evacuation of subdural hematomas and contusions may benefit from decompressive craniectomy in conjunction with lesion evacuation, even when elevated ICP is not a factor in the decision to perform surgery.

Tracheostomy in craniectomised survivors after traumatic brain injury: a cross-sectional analytical study

BACKGROUND

Decompressive craniectomy (DC) is a life-saving measure for traumatic brain injury (TBI). However, survivors may remain in a vegetative or minimally conscious state and require tracheostomy to facilitate airway management. In this cross-sectional analytical study, we investigated the predictors for tracheostomy requirement and influence of tracheostomy timing on outcomes in craniectomised survivors after TBI.

METHODS

We enrolled 160 patients undergoing DC and surviving >7 days after TBI in this 3-year retrospective study. The patients were subdivided into 2 groups based on whether tracheostomy was (N=38) or was not (N=122) performed. We identified intergroup differences in early clinical parameters. Multivariable logistic regression was used to adjust for independent predictors of the need for tracheostomy. Early tracheostomy was defined as the performance of the procedure within the first 10 days after DC. Intensive care unit (ICU) stay, hospital stay, mortality, and Glasgow outcome scale (GOS) were analysed according to the timing of the tracheostomy procedure.

RESULTS

After TBI, 24% of craniectomised survivors required tracheostomy. In the multivariate logistic regression mode, the significant factors related to the need for tracheostomy were age (odds ratio=1.041; p=0.002), the Glasgow coma score (GCS) at admission (odds ratio=0.733; p=0.005), and normal status of basal cisterns (odds ratio=0.000; p=0.008). The ICU stay was shorter for patients with early tracheostomy than for those undergoing late tracheostomy (p=0.004). The timing of tracheostomy had no influence on the hospital stay, mortality, or GOS.

CONCLUSION

Age and admission GCS were independent predictors of the need for tracheostomy in craniectomised survivors after TBI. If tracheostomy is necessary, an earlier procedure may assist in patient care.

Decompressive hemicraniectomy in pediatric patients with malignant middle cerebral artery infarction: case series and review of the literature

OBJECTIVE

Malignant middle cerebral artery infarction (mMCAI) is a life-threatening condition in pediatric patients. Despite strong evidence showing decreased morbidity and mortality in adult mMCAI patients with decompressive hemicraniectomy (DCH), there is a paucity of data on the use of DCH in children with similar conditions. Here we report experience from our center and perform a systematic review of published literature on outcomes after use of DCH in pediatric mMCAI patients.

METHODS

By retrospective chart review, we identified 3 children with large ischemic stroke who underwent DCH for life-threatening cerebral edema. Information was obtained about patient characteristics on admission, radiological features of the stroke, surgical procedures, complications of the DCH and cranioplasty, and functional outcomes during follow-up visits. We also reviewed the current literature on DCH in pediatric stroke.

RESULTS

DCH was performed in all 3 cases after development of pupillary dilatation. All 3 children survived and were ambulatory at the time of follow-up. Review of literature identified 12 other published case series describing 26 cases of DCH in pediatric patients with ischemic stroke. Descriptive statistical analysis of these cases is presented. Published reports suggest that a good outcome is possible even in the presence of signs of herniation, low preoperative Glasgow Coma Scale score, involvement of multiple vascular territories, or longer time to surgery in pediatric ischemic stroke patients.

CONCLUSIONS

The current data suggest a role for DCH in the management of cerebral edema in pediatric patients with mMCAI. Factors that help in prognostication for adult stroke patients undergoing DCH do not appear to convey similar information about the pediatric population. This highlights the urgent need for collaboration across institutes to further investigate this potentially life-saving procedure in pediatric stroke.

Management of intracerebral pressure in the neurosciences critical care unit

Management of intracranial pressure in neurocritical care remains a potentially valuable target for improvements in therapy and patient outcomes. Surrogate markers of increased intracranial pressure, invasive monitors, and standard therapy, as well as promising new approaches to improve cerebral compliance are discussed, and a current review of the literature addressing this metric in neuroscience critical care is provided.

Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy

OBJECT

Decompressive craniectomy is a life-saving measure for patients who have sustained traumatic brain injury (TBI), but patients undergoing this procedure may still die during an early phase of head injury. The aim of this study was to investigate the incidence, causes, and risk factors of 30-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy.

METHODS

The authors included 201 head-injured patients undergoing decompressive craniectomy in this 3-year retrospective study. The main outcome evaluated was 30-day mortality in patients who had undergone craniectomy after TBI. Demographic and clinical data, including information on death, were obtained for subsequent analysis. The authors identified differences between survivors and nonsurvivors in terms of clinical parameters; multivariate logistic regression was used to adjust for independent risk factors of short-term death.

RESULTS

The 30-day mortality rate was 26.4% in traumatically brain-injured patients undergoing decompressive craniectomy. The majority of deaths following decompression resulted from uncontrollable brain swelling and extensive brain infarction, which accounted for 79.2% of mortality. In the multivariate logistic regression mode, the 2 independent risk factors for 30-day mortality were age (OR 1.035 [95% CI 1.006-1.064]; p = 0.018) and Glasgow Coma Scale (GCS) score before decompressive craniectomy (OR 0.769 [95% CI 0.597-0.990]; p = 0.041).

CONCLUSIONS

There is a high 30-day mortality rate in traumatically brain-injured patients undergoing decompressive craniectomy. Most of the deaths are attributed to ongoing brain damage, even after decompression. Risk factors of short-term death, including age and preoperative GCS score, are important in patient selection for decompressive craniectomy, and these factors should be considered together to ensure the highest chance of surviving TBI.

Cranioplasty with bandaging. New forms of limitation of life support and organ donation

Most of transplanted organs are obtained from brain death (BD) donors. In neurocritical patients with catastrophic injuries and decompressive craniectomy (DC), which show a dreadful development in spite of this treatment, DC could be a futile tool to avoid natural progress to BD. We propose if cranial compressive bandage (cranioplasty with bandage) could be an ethically correct practice, similar to other life-sustaining treatment limitation (LSTL) common methods. Based on a clinical case, we contacted with the Assistance Ethics Committee and some bioethics professionals asking them two questions: 1) Is ethically correct to perform a cranioplasty with bandage in those patients with LSTL indication? 2) Thinking in organ donation possibility, is this option preferable? Conclusions 1) Cranioplasty with bandage could be considered an ethically acceptable LSTL practice, similar to other procedures. 2) It facilitates organ donation for transplant, which provides value-added because of its own social good. 3) In these cases, it is necessary to know previous patient's will or, in absentia, to obtain family consent after a detailed procedure report.

Comparative study of decompressive craniectomy in traumatic brain injury with or without mass lesion

OBJECTIVE

Decompressive craniectomy (DC) is one of the most ardently debated topics in traumatic brain injury (TBI) treatment. The aim of this study is to compare the differences between DC with and without mass evacuation in patients with TBI.

METHODS

From January 2005 to December 2009, 164 patients underwent DC at our centre. Seventy-one of the 164 patients underwent DC for diffuse injury (group B). Ninety-three patients underwent DC as part of an operation to treat a mass lesion (group A). Patient characteristics and post-operative outcomes were compared between the two groups.

RESULTS

Thirty-six patients died during this study (22.0%). Fifty-nine of these patients (36.0%) remained either vegetative (n = 30) or severely disabled (n = 29). Sixty-nine patients (42%) had a Glasgow Outcome Scale (GOS) score of 4 to 5. Three predictors were significantly related to 60-day mortality: age older than 50 years (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.01-5.52), abnormal pupillary response to light (OR, 3.79; 95% CI, 1.29-11.14), and DC with mass evacuation (OR, 0.31; 95% CI, 0.12-0.79). Mortality differed substantially between patients with (group A) and without (group B) mass evacuation (14.0% versus 32.4%). Only one predictor was significantly related to good outcome: Glasgow Coma Scale (GCS) score at admission: (OR, 2.43; and 95% CI, 1.39-4.24).

CONCLUSIONS

DC for patients with or without mass lesion has different patient characteristics. DC with mass evacuation has lower mortality than DC without mass evacuation. Outcome prediction following DC should be adjusted according to mass evacuation.

Decompressive craniectomy in children: single-center series and systematic review

BACKGROUND

Decompressive craniectomy (DC) is performed as a life-saving procedure in patients with intractably increased intracranial pressure after traumatic brain injury, bleeding, cerebral infarction, or brain swelling of other causes. However, the application of DC is as controversial in the pediatric population as it is in adults.

OBJECTIVE

To find factors influencing the outcome in pediatric patients who underwent DC because of sustained high intracranial pressure.

METHODS

Between April 2000 and December 2009, 34 pediatric patients (age 0-18 years) underwent DC. Patients were stratified according to the indication for DC. Outcome was assessed according to the modified Rankin Scale score at 6 months. MEDLINE was searched for published studies or reports of DC in pediatric patients to gain a larger population. Two reviewers independently extracted data.

RESULTS

Literature data, including the current series, revealed a total of 172 pediatric patients. Overall, a favorable outcome was achieved in 106 of 172 patients (62%). A favorable outcome was achieved in 25 of 36 patients without traumatic brain injury vs 81 of 136 patients with traumatic brain injury (69% vs 60%). Patients without signs of cerebral herniation had a better outcome than patients with unilateral or bilateral dilated pupils (73% vs 60% vs 45%, respectively).

CONCLUSION

The current data indicate that DC in children with traumatic or nontraumatic brain swelling might be warranted, regardless of the underlying cause. Despite mydriasis, a favorable outcome might be achieved in a significant number of pediatric patients. Nevertheless, careful individual decision making is needed for each patient, especially when signs of cerebral herniation have persisted for a long time.

Traumatic Brain Injury in the Elderly: Is it as Bad as we Think?

Traumatic brain injury in elderly patients is a neglected global disease burden. The main cause is fall, followed by motor vehicle accidents. This review article summarizes different aspects of geriatric traumatic brain injury, including epidemiology, pathology, and effects of comorbidities and pre-injury medications such as antiplatelets and anticoagulants. Functional outcome with or without surgical intervention, cognitive outcome, and psychiatric complications are discussed. Animal models are also reviewed in attempt to explain the relationship of aging and outcome, together with advances in stem cell research. Though elderly people in general did fare worse after traumatic brain injury, certain "younger elderly" people, aged 65-75 years, could have a comparable outcome to younger adults after minor to moderate head injury.

Cranial repair: how complicated is filling a "hole"?

In general, cranioplasty is viewed as a straightforward surgical procedure, and for many years the complications associated with the procedure have been underestimated. We reviewed our 5-year experience consisting of 218 cranioplasties. Study outcomes focused specifically on the occurrence of complications after cranioplasty. Autologous bone-assisted and prosthetic cranioplasties were considered. Variables described by other authors to be associated with complications were studied, including history of previous cranioplasty, wider craniectomy size, bifrontal craniectomy, and delayed cranioplasty. We also analyzed the influence of material used for craniectomy on the occurrence of complications. The overall complication rate was 19.7%. Nineteen cases of infection (8.7%), 5 cases of postoperative wound dehiscence (2.3%), 6 cases of epidural hemorrhage (2.8%), and 13 cases of cranioplasty dislocation (5.9%) were observed. Bifrontal cranioplasties were more frequently associated with complications (p=0.01; Fisher's exact test) and infection (p<0.0001; Fisher's exact test). Postoperative wound dehiscence was more frequently observed with hand-made or custom-made cranioplasties compared with autologous cranioplasties (p=0.02). Early cranioplasty (<3 months from craniectomy) was significantly associated with cranioplasty dislocation (p=0.03). Logistical regression analysis showed that the only factor independently associated with complication was the site of cranioplasty (p=0.01). In particular, patients with a bifrontal cranioplasty had a 2-fold increased risk of complication (CI 95 1.1-3.6, p=0.017) and a 2.5-fold increased risk of developing infection (CI 95 1.3-4.9, p=0.009) compared with hemispheric/bihemispheric cranioplasty. Our analysis confirms that cranioplasty is burdened by a significant complication rate. In this context, bifrontal cranioplasty is related to a higher risk of complication and, in particular, infection.

Decompressive craniectomy for elderly patients with traumatic brain injury: it's probably not worth the while

Decompressive craniectomy (DC) has been regarded as an ultima ratio measure in the treatment of refractory intracranial hypertension after brain injury. Most discussion about its benefits is based on studies performed in patients who are <65 years of age. The aim of this study was to identify patients aged ≥66 years who underwent DC after traumatic brain injury (TBI), in order to assess patient outcome and to correlate the values of potential predictors of survival on prognosis. From January 2002 to December 2009, 44 patients aged ≥66 underwent DC (follow-up, 12-102 months). Potential predictors of outcome were analyzed, including age, post-resuscitation Glasgow Coma Scale (GCS) score, presence of mass lesion, Simplified Acute Physiology Score (SAPS) II, Injury Severity Score (ISS), and timing of surgical decompression. Mortality was 48% at discharge from the intensive care unit (ICU), 57% at hospital discharge, and 77% at 1-year follow-up and at last follow-up. A bad outcome Glasgow Outcome Scale Dead-Vegetative State-Severely Disabled (GOS D-VS-SD) was observed in 36/44 patients both at hospital discharge and at 1-year follow-up. Mean SAPS II was 45.2 for patients who survived and 57.3 for patients who had died (p=0.0022). Patients who survived had a higher mean post-resuscitation GCS score (p=0.02). Logistical regression analysis indicated post-resuscitation GCS score as the only independent predictive factor for outcome. None of the 22 patients with a post-resuscitation GCS score of 3-5 had a good outcome, 2/10 (20%) patients with a post-resuscitation GCS score of 6-8 and 6/12 patients (50%) with a post-resuscitation GCS score ≥9 had a good outcome.

Cost-effectiveness of decompressive craniectomy in non-traumatic neurological emergencies

BACKGROUND

Decompressive craniectomy is used regularly in traumatic brain injury (TBI) and malignant middle cerebral artery infarction. Its benefits for other causes of non-traumatic brain swelling, if any, are unclear, especially after a devastating primary event.

METHODS

We evaluated the outcomes as well as treatment costs of all emergency decompressive craniectomies performed between the 2000 and 2006 in a single institution to lower intractable intracranial pressure, excluding the standard indications TBI and malignant middle cerebral infarction. The health-related quality of life (HRQoL) was evaluated on the Euroqol (EQ-5D) scale, and cost of a quality-adjusted life year (QALY) calculated.

RESULTS

The overall 3-year mortality rate was 62% for subarachnoid haemorrhage (SAH, 29 patients) and 31% for other neurological emergencies (13 patients). Patients with SAH were on average 13 years older than the other indications mean. Of the non-survivors, 45% died within a month and 95% within 1 year. Median EQ-5D index values were poor (0.15 for SAH and 0.62 for the other emergencies, versus 0.85 for the normal population), but of the survivors, 73% and 89% were able to live at home. The cost of neurosurgical treatment for one QALY was 11,000 € for SAH and 2000 € for other emergencies.

CONCLUSION

Mortality after non-traumatic neurological emergencies leading to decompressive craniectomy was high, and the HRQoL index of the survivors was poor. Most survivors were, however, able to live at home, and the cost of neurosurgical treatment for a QALY gained was acceptable.

Role of preoperative 3-dimensional computed tomography reconstruction in depressed skull fractures treated with craniectomy: a case report of forensic interest

Patients affected by cranial trauma with depressed skull fractures and increased intracranial pressure generally undergo neurosurgical intervention. Because craniotomy and craniectomy remove skull fragments and generate new fracture lines, they complicate forensic examination and sometimes prevent a clear identification of skull fracture etiology. A 3-dimensional reconstruction based on preoperative computed tomography (CT) scans, giving a picture of the injuries before surgical intervention, can help the forensic examiner in identifying skull fracture origin and the means of production.We report the case of a 41-year-old-man presenting at the emergency department with a depressed skull fracture at the vertex and bilateral subdural hemorrhage. The patient underwent 2 neurosurgical interventions (craniotomy and craniectomy) but died after 40 days of hospitalization in an intensive care unit. At autopsy, the absence of various bone fragments did not allow us to establish if the skull had been stricken by a blunt object or had hit the ground with high kinetic energy. To analyze bone injuries before craniectomy, a 3-dimensional CT reconstruction based on preoperative scans was performed. A comparative analysis between autoptic and radiological data allowed us to differentiate surgical from traumatic injuries. Moreover, based on the shape and size of the depressed skull fracture (measured from the CT reformations), we inferred that the man had been stricken by a cylindric blunt object with a diameter of about 3 cm.